Introducción de la metodología análisis modal de fallos y efectos (AMFE) como herramienta de gestión en una ese del distrito capital de II nivel

El presente trabajo expone la elaboración de un proceso sistemático para la identificación y clasificación de modos de fallo utilizando la metodología ANÁLISIS MODAL DE FALLOS Y EFECTOS (AMFE), como un procedimiento de gran utilidad para mejorar la calidad y seguridad de la prestación de servicios asistenciales. Se analizaron 254 modos de fallo, en el servicio de urgencias de una ESE de II Nivel del Distrito Capital, se utilizó una herramienta de selección de procesos denominada Matriz de Priorización utilizada por el Centro de Gestión Hospitalaria con algunas adaptaciones de acuerdo con las necesidades institucionales. Se calificaron 227 de ellos correspondiendo a un 89,37%. Se entrevistaron 48 médicos, 27 enfermeras, 27 auxiliares de enfermería y 9 camilleros, para un total de 111 colaboradores que corresponden al 30% del total del personal del servicio de urgencias. Se generó una hoja de control de calidad (aceptación) del ejercicio con un porcentaje total del 85%, teniendo como resultado que 102 personas de las 111 encuestadas, diligenciaron correctamente la totalidad de los campos del formato AMFE. Se buscó Implementar el uso de la metodología AMFE como herramienta de gestión y mejora de procesos institucionales, realizando una prueba piloto al proceso seleccionado y evaluando si esta metodología se podía aplicar a otros procesos asistenciales. Se observó que de la totalidad de los modos de fallo el mayor valor de criticidad se encontró en el rango de 45 puntos. Se determinaron 11 modos de fallos en esta categoría, los cuales se encuentran dos asociados dos están asociados con el acceso del paciente a la institución, siete relacionados con el Registro e Ingreso del usuario, uno relacionado con la planeación de la atención y dos relacionados con la ejecución del tratamiento. Palabras claves: Análisis Modal De Fallos y Efectos (AMFE), urgencias, mejora continua.

An automated failure mode and effect analysis based on high-level design specificication with behavior trees

Formal methods have significant benefits for developing safety critical systems, in that they allow for correctness proofs, model checking safety and liveness properties, deadlock checking, etc. However, formal methods do not scale very well and demand specialist skills, when developing real-world systems. For these reasons, development and analysis of large-scale safety critical systems will require effective integration of formal and informal methods. In this paper, we use such an integrative approach to automate Failure Modes and Effects Analysis (FMEA), a widely used system safety analysis technique, using a high-level graphical modelling notation (Behavior Trees) and model checking. We inject component failure modes into the Behavior Trees and translate the resulting Behavior Trees to SAL code. This enables us to model check if the system in the presence of these faults satisfies its safety properties, specified by temporal logic formulas. The benefit of this process is tool support that automates the tedious and error-prone aspects of FMEA.

On failure modes and strength characterization of brittle disordered materials under uniaxial compression and tension

With a newly developed Material Failure Process Analysis code (MFPA(2D)), influence of hetero geneity on fracture processes and strength characterization of brittle disorder materials such as rock or concrete is numerically studied under uniaxial compression and tension conditions. It is found th at, due to the heterogeneity of the disordered material, relatively more diffused micro-fractures appear in the early stage of loading. Different from homogeneous materials such as glass, macro-crack nucleation starts well before the peak stress is reached and the crack propagation and coalescence can be traced, which can be taken as a precursory to predict the macro-fracture of the material. The presence of residual strength in the post-peak region and the resemblance in the stress-strain curves between tension and compression are significant results and are found to be dependent on the heterogeneity of the specimens. Examples showing the tentative applications of MFPA(2D) in modeling failure of composite materials and rock or civil engineering problem are also given in this paper.

Aplicação dos conceitos de RCM e a ferramenta FMEA no aumento de confiabilidade em equipamentos de uma indústria química

The growing demand for quality at competitive prices and fast production process put to the test function in the industrial Maintenance. The need for equipment with high availability to fit this fierce competitiveness makes maintenance becomes essentially reliable. Despite this current context, many companies still have an old view of maintenance, focused only on corrective services, and proposals for change are often neglected due to the sense of urgency day to day. Thus, this study aims to demonstrate through theoretical applicability of simple tool, but of great value in increasing reliability within the maintenance sector of an industry, applying the concepts of Reliability Centered Maintenance – RCM and Analysis tool Failure Modes and Effects – FMEA in equipment of a chemical company directly involved in the manufacturing process of the brake fluid, which this product is used in vehicles around the country. That way, you can identify the types, occurrence and criticality of each failure and evaluate assertively decision making for each device, avoiding unnecessary downtime and potential failures of the same

Failure modes and fatigue behavior of conventional and refilled friction stir spot welds in AA 6061-T6 sheets

The fatigue behavior of conventional friction stir spot welding (FSSW) and friction stir spot welding refilled by the friction forming process (FSSW-FFP) in aluminum 6061-T6 lap shear specimens, are investigated based on the experimental observations. Optical micrographs of the welds after fatigue failure in both the cases are examined to study the fatigue crack propagation and failure modes. Experimental results indicate that the fatigue strength of the FSSW-FFP weld samples is higher than that of the conventional FSSW samples at all loads. Fracture surfaces are analyzed in detail using the scanning electron microscope. (C) 2013 Elsevier Ltd. All rights reserved.

Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis

Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days. CONCLUSIONS Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.

Aplicação do FMEA na avaliação de risco de taludes e muros de contenção tradicionais em alvenaria de pedra

Ao longo das últimas décadas o município de Amarante tem-se deparado com inúmeros problemas de instabilidade de estruturas de suporte de terras, maioritariamente instabilidade de taludes artificiais, (escavação e/ou aterro) e muros de contenção tradicionais em alvenaria de pedra. A unidade técnica de projeto, ou UTP da Câmara Municipal de Amarante tem vindo a elaborar estudos, projetos e adjudicar as obras para repor a normalidade apos a instabilização desses elementos, contudo a frequência de ocorrência destes fenómenos e os recursos necessários para a sua resolução ultrapassam a capacidade desta unidade, levando a que muitos destes casos se arrastem durante anos antes de ser reposta a sua normalidade. Perante este panorama revelou-se necessário efetuar um estudo de forma a listar, avaliar e priorizar os vários casos de instabilidade existentes, para uma eficiente alocação dos recursos disponíveis. Esta análise pretende ainda identificar as principais causas de instabilidade destas estruturas, de forma a eliminar ou mitigar a ocorrência de futuros problemas semelhantes. Para o estudo destes elementos de contenção de terras adotou-se o método de análise de risco conhecido como FMEA, “Failure Modes and Effects Analysis” ou Analise dos Modos de Falha e Efeitos, com as adaptações necessárias de forma a maximizar a confiabilidade das avaliações mediante a especificidade dos casos a avaliar e realidade da instituição.

Metodologia integrada para mapeamento de falhas: uma proposta de utilização conjunta do mapeamento de processos com as técnicas FTA, FMEA e a análise crítica de especialistas

As falhas representam não conformidades nas atividades produtivas, de tal modo que pesquisas para seu controle e prevenção são, no mínimo, desejáveis. Na literatura sobre o assunto, observa-se uma gama variada de técnicas, porém, quase sempre, usadas isoladamente e, em poucos casos, no setor de serviços. Observando essa lacuna, propõe-se uma metodologia de Mapeamento de Falhas que integra diferentes abordagens que se complementam, aproveitando-se o potencial e o benefício de cada técnica para análise e controle de falhas. Para a consecução dessa proposta, efetuou-se uma pesquisa bibliográfica para conceituação e entendimento das técnicas utilizadas, um estudo e análise de integração dessas técnicas e, por fim, um exemplo real de aplicação em processo notarial de serviço, tema este ainda não explorado na literatura pertinente e, portanto, bastante auspicioso. Como resultado, observa-se uma ferramenta que permite uma visualização completa e objetiva das atividades desencadeadas pelos processos, seus pontos críticos e suas potenciais falhas, podendo ser aplicada com propriedade em empresas de prestação de serviços.

Decision-making in product quality based on failure knowledge

Decision-making in product quality is an indispensable stage in product development, in order to reduce product development risk. Based on the identification of the deficiencies of quality function deployment (QFD) and failure modes and effects analysis (FMEA), a novel decision-making method is presented that draws upon a knowledge network of failure scenarios. An ontological expression of failure scenarios is presented together with a framework of failure knowledge network (FKN). According to the roles of quality characteristics (QCs) in failure processing, QCs are set into three categories namely perceptible QCs, restrictive QCs, and controllable QCs, which present the monitor targets, control targets and improvement targets respectively for quality management. A mathematical model and algorithms based on the analytic network process (ANP) is introduced for calculating the priority of QCs with respect to different development scenarios. A case study is provided according to the proposed decision-making procedure based on FKN. This methodology is applied in the propeller design process to solve the problem of prioritising QCs. This paper provides a practical approach for decision-making in product quality. Copyright © 2011 Inderscience Enterprises Ltd.

Characterization of Failure Modes in CFRP Composites - An ANN Approach

Carbon fiber reinforced polymer (CFRP) composite specimens with different thickness, geometry, and stacking sequences were subjected to fatigue spectrum loading in stages. Another set of specimens was subjected to static compression load. On-line acoustic Emission (AE) monitoring was carried out during these tests. Two artificial neural networks, Kohonen-self organizing feature map (KSOM), and multi-layer perceptron (MLP) have been developed for AE signal analysis. AE signals from specimens were clustered using the unsupervised learning KSOM. These clusters were correlated to the failure modes using available a priori information such as AE signal amplitude distributions, time of occurrence of signals, ultrasonic imaging, design of the laminates (stacking sequences, orientation of fibers), and AE parametric plots. Thereafter, AE signals generated from the rest of the specimens were classified by supervised learning MLP. The network developed is made suitable for on-line monitoring of AE signals in the presence of noise, which can be used for detection and identification of failure modes and their growth. The results indicate that the characteristics of AE signals from different failure modes in CFRP remain largely unaffected by the type of load, fiber orientation, and stacking sequences, they being representatives of the type of failure phenomena. The type of loading can have effect only on the extent of damage allowed before the specimens fail and hence on the number of AE signals during the test. The artificial neural networks (ANN) developed and the methods and procedures adopted show significant success in AE signal characterization under noisy environment (detection and identification of failure modes and their growth).

Desenvolvimento de um método para diagnose de falhas na operação de navios transportadores de gás natural liquefeito através de redes bayesianas.

O Gás Natural Liquefeito (GNL) tem, aos poucos, se tornado uma importante opção para a diversificação da matriz energética brasileira. Os navios metaneiros são os responsáveis pelo transporte do GNL desde as plantas de liquefação até as de regaseificação. Dada a importância, bem como a periculosidade, das operações de transporte e de carga e descarga de navios metaneiros, torna-se necessário não só um bom plano de manutenção como também um sistema de detecção de falhas que podem ocorrer durante estes processos. Este trabalho apresenta um método de diagnose de falhas para a operação de carga e descarga de navios transportadores de GNL através da utilização de Redes Bayesianas em conjunto com técnicas de análise de confiabilidade, como a Análise de Modos e Efeitos de Falhas (FMEA) e a Análise de Árvores de Falhas (FTA). O método proposto indica, através da leitura de sensores presentes no sistema de carga e descarga, quais os componentes que mais provavelmente estão em falha. O método fornece uma abordagem bem estruturada para a construção das Redes Bayesianas utilizadas na diagnose de falhas do sistema.

Failure Mechanisms and Local Scour at Coastal Structures induced by Tsunamis

On March 11 2011, an exceptionally large tsunami event was triggered by a massive earthquake offshore, the northeast coast of Japan, which affected coastal infrastructure such as seawalls, coastal dikes and breakwaters in the Tohoku region. Such infrastructure was built to protect against the Level 1 tsunamis that previously hit the region, but not for events as significant as the 2011 Tohoku tsunami, which was categorized as a Level 2 tsunami [Shibayama et al. 2013]. The failure mechanisms of concrete-armoured dikes, breakwaters and seawalls due to Level 2 tsunamis are still not fully understood by researchers and engineers. This paper investigates the failure modes and mechanisms of damaged coastal structures in Miyagi and Fukushima Prefectures, following the authors' post-disaster field surveys carried out between 2011 and 2013. Six significant failure mechanisms were identified for the coastal dikes and seawalls affected by this tsunami: 1) Leeward toe scour failure, 2) Crown armour failure, 3) Leeward slope armour failure, 4) Seaward toe and armour failure, 5) Overturning failure, and 6) Parapet wall failure, in which leeward toe scour being recognized as the major failure mechanism in most surveyed locations. The authors also propose a simple practical mathematical model for predicting the scour depth at the leeward toe of the coastal dikes, by considering the effects of the tsunami hydrodynamics, the soil properties and the type of structure. The key advantage of this model is that it depends entirely on quantities that are measurable in the field. Furthermore this model was further refined by conducting a series of hydraulic model experiments aimed to understand the governing factors of the leeward toe scour failure. Finally, based on the results obtained, key recommendations are given for the design of resilient coastal defence structures that can survive a level 2 tsunami event.

Metodologia para retroalimentação do ciclo de desenvolvimento de produto com dados de confiabilidade oriundos da utilização do produto em campo

Esta dissertação apresenta uma metodologia de retroalimentação do ciclo de desenvolvimento de produtos, com ênfase na fase de projeto, a partir de dados obtidos em estudos de confiabilidade. A metodologia é proposta com base no escopo da norma QS-9000, norma esta que vem sendo utilizada por fornecedores e sub-fornecedores da indústria automobilística no mundo inteiro. Um estudo de caso permitiu que a metodologia fosse implementada em uma empresa certificada na norma. São aplicadas retroalimentações em ferramentas como Desdobramento da Função Qualidade (QFD), Análise dos Modos e Efeitos de Falha de Produto (DFMEA) e de Processo (PFMEA). Os resultados obtidos demonstraram que a metodologia de retroalimentação proposta é uma ferramenta útil na maturação de um produto, através da utilização dos dados de falhas em campo, bem como no momento do desenvolvimento de um produto novo, que irá suceder o atual, através da utilização da voz do cliente e dos dados de falha em campo de forma ordenada.

Approach to integrate product conceptual design information into a computer-aided design system

Commercial computer-aided design systems support the geometric definition of product, but they lack utilities to support initial design stages. Typical tasks such as customer need capture, functional requirement formalization, or design parameter definition are conducted in applications that, for instance, support ?quality function deployment? and ?failure modes and effects analysis? techniques. Such applications are noninteroperable with the computer-aided design systems, leading to discontinuous design information flows. This study addresses this issue and proposes a method to enhance the integration of design information generated in the early design stages into a commercial computer-aided design system. To demonstrate the feasibility of the approach adopted, a prototype application was developed and two case studies were executed.