Characterization of human and instrument related measurement errors

Measurement is the act or the result of a quantitative comparison between a given quantity and a quantity of the same kind chosen as a unit. It is generally agreed that all measurements contain errors. In a measuring system where both a measuring instrument and a human being taking the measurement using a preset process, the measurement error could be due to the instrument, the process or the human being involved. The first part of the study is devoted to understanding the human errors in measurement. For that, selected person related and selected work related factors that could affect measurement errors have been identified. Though these are well known, the exact extent of the error and the extent of effect of different factors on human errors in measurement are less reported. Characterization of human errors in measurement is done by conducting an experimental study using different subjects, where the factors were changed one at a time and the measurements made by them recorded. From the pre‐experiment survey research studies, it is observed that the respondents could not give the correct answers to questions related to the correct values [extent] of human related measurement errors. This confirmed the fears expressed regarding lack of knowledge about the extent of human related measurement errors among professionals associated with quality. But in postexperiment phase of survey study, it is observed that the answers regarding the extent of human related measurement errors has improved significantly since the answer choices were provided based on the experimental study. It is hoped that this work will help users of measurement in practice to better understand and manage the phenomena of human related errors in measurement.

Mechatronic system for ABO human blood typing

In medical emergency situations, when a patient needs a blood transfusion, the universal blood type O− is administered. This procedure may lead to the depletion of stock reserves of O− blood. Nowadays, there is no commercial equipment capable of determining the patient's blood type in situ, in a fast and reliable process. Human blood typing is usually performed through the manual test, which involves a macroscopic observation and interpretation of the results by an analyst. This test, despite of having a fast response time, may lead to human errors, which sometimes can be fatal to the patient. This paper presents the development of an automatic mechatronic prototype for determining human blood typing (ABO and Rh systems) through image processing techniques. The prototype design takes into account the characteristics of reliability of analysis, portability, and response time allowing the system to be used in emergency situations. The developed prototype performs blood and reagents mixture acquires the resultant image and processes the data (based on image processing techniques) to determine the sample blood type. It was tested in a laboratory, using cataloged samples of blood types, provided by the Portuguese Institute of Blood and Transplantation. Hereafter, it is expected to test and validate the prototype in clinical environments.

K-Surfer: a KNIME extension for the management and analysis of Human brain MRI FreeSurfer/FSL data

Human brain imaging techniques, such as Magnetic Resonance Imaging (MRI) or Diffusion Tensor Imaging (DTI), have been established as scientific and diagnostic tools and their adoption is growing in popularity. Statistical methods, machine learning and data mining algorithms have successfully been adopted to extract predictive and descriptive models from neuroimage data. However, the knowledge discovery process typically requires also the adoption of pre-processing, post-processing and visualisation techniques in complex data workflows. Currently, a main problem for the integrated preprocessing and mining of MRI data is the lack of comprehensive platforms able to avoid the manual invocation of preprocessing and mining tools, that yields to an error-prone and inefficient process. In this work we present K-Surfer, a novel plug-in of the Konstanz Information Miner (KNIME) workbench, that automatizes the preprocessing of brain images and leverages the mining capabilities of KNIME in an integrated way. K-Surfer supports the importing, filtering, merging and pre-processing of neuroimage data from FreeSurfer, a tool for human brain MRI feature extraction and interpretation. K-Surfer automatizes the steps for importing FreeSurfer data, reducing time costs, eliminating human errors and enabling the design of complex analytics workflow for neuroimage data by leveraging the rich functionalities available in the KNIME workbench.

A study on human error in the interaction with the computer systems

The term human factor is used by professionals of various fields meant for understanding the behavior of human beings at work. The human being, while developing a cooperative activity with a computer system, is subject to cause an undesirable situation in his/her task. This paper starts from the principle that human errors may be considered as a cause or factor contributing to a series of accidents and incidents in many diversified fields in which human beings interact with automated systems. We propose a simulator of performance in error with potentiality to assist the Human Computer Interaction (HCI) project manager in the construction of the critical systems. © 2011 Springer-Verlag.

Toward a cognitive taxonomy of medical errors.

One critical step in addressing and resolving the problems associated with human errors is the development of a cognitive taxonomy of such errors. In the case of errors, such a taxonomy may be developed (1) to categorize all types of errors along cognitive dimensions, (2) to associate each type of error with a specific underlying cognitive mechanism, (3) to explain why, and even predict when and where, a specific error will occur, and (4) to generate intervention strategies for each type of error. Based on Reason's (1992) definition of human errors and Norman's (1986) cognitive theory of human action, we have developed a preliminary action-based cognitive taxonomy of errors that largely satisfies these four criteria in the domain of medicine. We discuss initial steps for applying this taxonomy to develop an online medical error reporting system that not only categorizes errors but also identifies problems and generates solutions.

Formal analysis of human-computer interaction using model checking

Experiments with simulators allow psychologists to better understand the causes of human errors and build models of cognitive processes to be used in human reliability assessment (HRA). This paper investigates an approach to task failure analysis based on patterns of behaviour, by contrast to more traditional event-based approaches. It considers, as a case study, a formal model of an air traffic control (ATC) system which incorporates controller behaviour. The cognitive model is formalised in the CSP process algebra. Patterns of behaviour are expressed as temporal logic properties. Then a model-checking technique is used to verify whether the decomposition of the operator's behaviour into patterns is sound and complete with respect to the cognitive model. The decomposition is shown to be incomplete and a new behavioural pattern is identified, which appears to have been overlooked in the analysis of the data provided by the experiments with the simulator. This illustrates how formal analysis of operator models can yield fresh insights into how failures may arise in interactive systems.

Factors affecting human reliability in the chemical process industry

This research was concerned with identifying factors which may influence human reliability within chemical process plants - these factors are referred to as Performance Shaping Factors (PSFs). Following a period of familiarization within the industry, a number of case studies were undertaken covering a range of basic influencing factors. Plant records and site `lost time incident reports' were also used as supporting evidence for identifying and classifying PSFs. In parallel to the investigative research, the available literature appertaining to human reliability assessment and PSFs was considered in relation to the chemical process plan environment. As a direct result of this work, a PSF classification structure has been produced with an accompanying detailed listing. Phase two of the research considered the identification of important individual PSFs for specific situations. Based on the experience and data gained during phase one, it emerged that certain generic features of a task influenced PSF relevance. This led to the establishment of a finite set of generic task groups and response types. Similarly, certain PSFs influence some human errors more than others. The result was a set of error type key words, plus the identification and classification of error causes with their underlying error mechanisms. By linking all these aspects together, a comprehensive methodology has been forwarded as the basis of a computerized aid for system designers. To recapitulate, the major results of this research have been: One, the development of a comprehensive PSF listing specifically for the chemical process industries with a classification structure that facilitates future updates; and two, a model of identifying relevant SPFs and their order of priority. Future requirements are the evaluation of the PSF listing and the identification method. The latter must be considered both in terms of `useability' and its success as a design enhancer, in terms of an observable reduction in important human errors.

ETIKETAGGER: herramienta para el etiquetaje de secuencias de imágenes

La adaptación del reconocimiento de objetos sobre la robótica móvil requiere un enfoque y nuevas aplicaciones que optimicen el entrenamiento de los robots para obtener resultados satisfactorios. Es conocido que el proceso de entrenamiento es largo y tedioso, donde la intervención humana es absolutamente necesaria para supervisar el comportamiento del robot y la dirección hacia los objetivos. Es por esta razón que se ha desarrollado una herramienta que reduce notablemente el esfuerzo humano que se debe hacer para esta supervisión, automatizando el proceso necesario para obtener una evaluación de resultados, y minimizando el tiempo que se malgasta debido a errores humanos o falta de infraestructuras.

Inhimillisten virheiden tarkastelu ydinvoimalaitosten käyttökokemusten hyödyntämisessä

Tässä työssä on kuvattu ydinvoimalaitosten käyttökokemusten tutkimusta keskittyen erityisesti inhimillisten toimintojen tarkasteluun. Työssä on kerrottu kansainvälisistä vaatimuksista ja järjestöistä sekä yleisesti käyttökokemusten tutkimuksessa käytössä olevista menetelmistä keskittyen perussyyanalyysimenetelmiin. Suomen osalta työssä on käsitelty lainsäädännön asettamia velvoitteita ja muita vaatimuksia, jotka ydinvoima-alalla koostuvat lähinnä Säteilyturvakeskuksen YVL-ohjeista. Viranomaisena toimivan Säteilyturvakeskuksen, alan tutkimusta suorittavan Valtion teknillisen tutkimuskeskuksen ja Teollisuuden Voima Oy:n käyttökokemusten tutkimiseen liittyvät organisaatiot ja menettelytavat on esitelty. Fortum Power and Heat Oy:n omistaman ja käyttämän Loviisan ydinvoimalaitoksen käyttökokemusten hyödyntäminen on käsitelty tarkemmin. Loviisan voimalaitoksen organisaatio ja käyttökokemusten sekä inhimillisten virheiden käsittelymenetelmiä on esitelty ja analysoitu. Työn alkuvaiheessa Loviisan voimalaitoksella inhimillisistä virheistä kerätystä tiedosta koottu tietokanta järjesteltiin kuntoon. Järjestelyn jälkeen tietoa analysoitiin ja analysoinnin tulokset on esitetty tässä työssä. Sekä järjestelyn että analysoinnin aikana havaitut kehityskohteet kirjattiin muistiin. Pienet toimenpiteet suoritettiin heti ja suuremmat kirjattiin tämän työn toimenpide-ehdotuksiin. Kehittämiskeinoja on ehdotettu virheiden luokittelumenetelmään ja käyttökokemusten käsittelymenetelmiin.

Poka-yoke for mass customization

Producing high quality products and services is one of the key concerns in order to keep up with the competition in the global markets. Companies are putting a great effort on preventing customers having faulty products and services by any means. However, the total elimination of mistakes in manufacturing processes has always been a great challenge for quality management. In this thesis the applicability of poka-yoke methodology in reducing the number of quality failures in the case company has been studied. Poka-yoke stands for the mistake-proofing and is mainly developed for the purpose of eliminating human errors in manufacturing processes. Inspection techniques; judgment, informative and source inspection are in the core of this methodology. Mass customization and large configurability of products leads to situation where the root causes of quality problems may vary a lot. To study the effects of these factors extensive analysis of quality failures was conducted. Recommendations and proposals for further actions regarding problem solving processes and utilization of mistake-proofing methods were provided on the basis of the analysis.

Transforming Maritime Safety Culture. Evaluation of the impacts of the ISM Code on maritime safety culture in Finland

The purpose of the METKU Project (Development of Maritime Safety Culture) is to study how the ISM Code has influenced the safety culture in the maritime industry. This literature review is written as a part of the Work Package 2 which is conducted by the University of Turku, Centre for Maritime Studies. The maritime traffic is rapidly growing in the Baltic Sea which leads to a growing risk of maritime accidents. Particularly in the Gulf of Finland, the high volume of traffic causes a high risk of maritime accidents. The growing risks give us good reasons for implementing the research project concerning maritime safety and the effectiveness of the safety measures, such as the safety management systems. In order to reduce maritime safety risks, the safety management systems should be further developed. The METKU Project has been launched to examine the improvements which can be done to the safety management systems. Human errors are considered as the most important reason for maritime accidents. The international safety management code (the ISM Code) has been established to cut down the occurrence of human errors by creating a safety-oriented organizational culture for the maritime industry. The ISM Code requires that a company should provide safe practices in ship operation and a safe working environment and establish safeguards against all identified risk. The fundamental idea of the ISM Code is that companies should continuously improve safety. The commitment of the top management is essential for implementing a safety-oriented culture in a company. The ISM Code has brought a significant contribution to the progress of maritime safety in recent years. Shipping companies and ships’ crews are more environmentally friendly and more safety-oriented than 12 years ago. This has been showed by several studies which have been analysed for this literature research. Nevertheless, the direct effect and influence of the ISM Code on maritime safety could not be isolated very well. No quantitative measurement (statistics/hard data) could be found in order to present the impacts of the ISM Code on maritime safety. In this study it has been discovered that safety culture has emerged and it is developing in the maritime industry. Even though the roots of the safety culture have been established there are still serious barriers to the breakthrough of the safety management. These barriers could be envisaged as cultural factors preventing the safety process. Even though the ISM Code has been effective over a decade, the old-established behaviour which is based on the old day’s maritime culture still occurs. In the next phase of this research project, these cultural factors shall be analysed in regard to the present safety culture of the maritime industry in Finland.

Caracterização físico-química de queijo prato por espectroscopia no infravermelho e regressão de mínimos quadrados parciais

In this work an analytical methodology for the determination of relevant physicochemical parameters of prato cheese is reported, using infrared spectroscopy (DRIFT) and partial least squares regression (PLS). Several multivariate models were developed, using different spectral regions and preprocessing routines. In general, good precision and accuracy was observed for all studied parameters (fat, protein, moisture, total solids, ashes and pH) with standard deviations comparable with those provided by the conventional methodologies. The implantation of this multivariate routine involves significant analytical advantages, including reduction of cost and time of analysis, minimization of human errors, and elimination of chemical residues.

Suunnitellun alas- ja ylösajon todennäköisyysperustainen riskianalyysi ydinvoimalaitokselle

Työssä tehtiin ydinvoimalaitoksen suunnitellun alas- ja ylösajon todennäköisyysperus-tainen riskianalyysi. Suunnitellun alasajon analyysi sisälsi Teollisuuden Voima Oyj:n käyttämän vanhan PRA-mallin päivityksen ja laajentamisen. Ylösajon analyysiä varten kehitettiin kokonaan uusi malli. Diplomityöselostuksen alussa on yleinen katsaus luotettavuustekniikan käsitteisiin, pe-rusperiaatteisiin ja työkaluihin. Sitten on esitelty laitostekniikkaa tärkeimpien alas- ja ylösajoihin osallistuvien järjestelmien osalta. Myös normaalit alas- ja ylösajotoimenpi-teet on kuvattu. Yleisen teoriaosuuden jälkeen on keskitytty uusien mallien muodosta-miseen. Työssä käytetyt oletukset ja arviot on esitelty perusteluineen. Uudet tapahtuma- ja vikapuut sekä niiden perusteella lasketut sydänvaurioriskit johtopäätöksineen on käy-ty läpi selostuksen lopussa. Alkutapahtumataajuuksien määrittäminen tehtiin vikapuiden avulla, joissa huomioitiin komponenttivikojen, inhimillisten virheiden ja ulkoisten tekijöiden vaikutus. Aiemmin alkutapahtumat oli määritetty pääasiassa käyttöhistorian perusteella. Uusi määrittelytapa antaa eri vikaantumistapojen välille paremman kuvan niiden keskinäisestä merkitykses-tä sekä paremman päivitettävyyden laitosmuutosten yhteydessä. Mallien avulla voidaan laskea alas- ja ylösajon merkitys kokonaissydänvauriotaajuuteen entistä yksityiskohtaisemmin. Tuloksia voidaan myös hyödyntää laitosten vikatilanteis-sa, kun vertaillaan jatketun käytön ja mahdollisten korjaustöiden vaatiman alas- ja ylösajon riskejä. Uusien mallien antamat tulokset laskivat vain hieman kokonaissydän-vauriotaajuutta, mutta merkittävästi alasajon vaikutusta siihen. Ylösajosta aiheutuva riskinlisä oli noin puolet alasajon riskistä.

Satamatoimijoiden riskienhallinta alusrajapinnassa, case HaminaKotkan kaasu- ja nestesatama

This study examined the risk management of port operators in the surface of vessel and terminal. This study was specially focused on the safety aspects as well as operational risks in surface of port of HaminaKotka liquid bulk terminal. Operational risks are examined during loading and unloading only. The theory of this study is based on strategy and competence of organizations and introducing different kind of methods of risk analysis. In addition, safety and directives of liquid bulk terminal is examined. Process scenario is represented concerning risks and risk management occurring in the surface of vessel and terminal. Finally the affect of human errors for the occurred accidents are examined. The method of explore was survey method. Survey was implemented via e-mail and enquiry was formatted as multiple choice enquiries. The main outcome of this study was that security level among enterprises operating in the liquid bulk terminal is high. Each enterprise has chosen the best risk analysis methods, which are suitable for their purposes. There is not one risk analysis available only used by every enterprise in the liquid bulk terminal. Using coherent risk analysis would clear out the everyday activities on that area. Greater presence of port master would also be desirable during every day activities in liquid bulk terminal.

Benefits and challenges of supply chain finance business process automation : A case study in ING Bank

Supply chain finance, a financial product provided by the bank, has gained increasing attention and popularity over the last few years. Supply chain finance helps the corporate clients to optimize their financial flows along the supply chain. One characteristic of supply chain finance is that it aims to provide automated solutions. Therefore, the business process automation of supply chain finance is a very interesting and important topic for study. In this study, the business process automation of supply chain finance within the case organization, ING, is analysed. The purpose is to: (1) Identify the benefits to understand the importance to automate supply chain finance business process; (2) Find out the existing automation degree in the supply chain finance business process within the case bank to see what’s the situation now and how to improve in the future; (3) Discover the challenges in the further automation of supply chain finance business process. Firstly, the study finds out that supply chain finance business process automation can bring many benefits to the bank. Automation can improve productivity by using less time and human labour in the business process, and by providing scalable solutions. Automation can also improve quality of the service by reducing the human errors. Last but not least, automation can improve internal governance by providing enhanced visibility of the business process. Because of these potential benefits, many banks are actively seeking solutions to automate their supply chain finance business process. Then, the current automation situation with the case bank is analysed with the help of business process modelling. The supply chain finance business process within the case bank can be further divided into several sub processes: daily transaction, buyer sales and setup, supplier onboarding, contract management, customer services and supports, and contract termination. The study finds out that the daily transaction process is already a highly automated, which is carried out through the web-based trading platform. However, for other business the automation degree is relatively low. Among these business processes, supplier onboarding is most needed for further automation. Then, some solutions are also suggested to automate the supplier onboarding business process. In the end, the study also foresees some challenges during the further automation of supply chain finance business process in the case bank. Some suggestions are also given to deal with these challenges.