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All sourcesNASA NTRSDOE OSTI
DOE OSTI2015

Framework for Modeling High-Impact, Low-Frequency Power Grid Events to Support Risk-Informed Decisions

Natural and man-made hazardous events resulting in loss of grid infrastructure assets challenge the electric power grid’s security and resilience. However, the planning and allocation of appropriate contingency resources for such events requires an understanding of their likelihood and the extent of their potential impact. Where these events are of low likelihood, a risk-informed perspective on planning can be problematic as there exists an insufficient statistical basis to directly estimate the probabilities and consequences of their occurrence. Since risk-informed decisions rely on such knowledge, a basis for modeling the risk associated with high-impact low frequency events (HILFs) is essential. Insights from such a model can inform where resources are most rationally and effectively expended. The present effort is focused on development of a HILF risk assessment framework. Such a framework is intended to provide the conceptual and overarching technical basis for the development of HILF risk models that can inform decision makers across numerous stakeholder sectors. The North American Electric Reliability Corporation (NERC) 2014 Standard TPL-001-4 considers severe events for transmission reliability planning, but does not address events of such severity that they have the potential to fail a substantial fraction of grid assets over a region, such as geomagnetic disturbances (GMD), extreme seismic events, and coordinated cyber-physical attacks. These are beyond current planning guidelines. As noted, the risks associated with such events cannot be statistically estimated based on historic experience; however, there does exist a stable of risk modeling techniques for rare events that have proven of value across a wide range of engineering application domains. There is an active and growing interest in evaluating the value of risk management techniques in the State transmission planning and emergency response communities, some of this interest in the context of grid modernization activities. The availability of a grid HILF risk model, integrated across multi-hazard domains which, when interrogated, can support transparent, defensible and effective decisions, is an attractive prospect among these communities. In this report, we document an integrated HILF risk framework intended to inform the development of risk models. These models would be based on the systematic and comprehensive (to within scope) characterization of hazards to the level of detail required for modeling risk, identification of the stressors associated with the hazards (i.e., the means of impacting grid and supporting infrastructure), characterization of the vulnerability of assets to these stressors and the probabilities of asset compromise, the grid’s dynamic response to the asset failures, and assessment of subsequent severities of consequence with respect to selected impact metrics, such as power outage duration and geographic reach. Specifically, the current framework is being developed to;1. Provide the conceptual and overarching technical paradigms for the development of risk models; 2. Identify the classes of models required to implement the framework - providing examples of existing models, and also identifying where modeling gaps exist; 3. Identify the types of data required, addressing circumstances under which data are sparse and the formal elicitation of informed judgment might be required; and 4. Identify means by which the resultant risk models might be interrogated to form the necessary basis for risk management.

97 MATHEMATICS AND COMPUTING↗
DOE OSTI2024

Current Practices in Distribution Utility Resilience Planning for Wildfires

This report is part of a series of hazard-focused case studies examining common practices in electric utility resilience planning. We use standard terminology defining resilience as the ability to anticipate, withstand, absorb, and recover from hazards that cause long duration outages. We distinguish between reliability and resilience using IEEE 1366-2022, which defines major events as "an event that exceeds reasonable design and/or operational limits of the electric power system." Resilience planning is focused on major event days, and reliability planning is focused on non-major event days. Utility resilience plans are assessed according to common resilience components identified in existing resilience frameworks. The focus of this report is on wildfires. Standalone reports focusing on severe storms (including hurricanes and non-winter storms) and winter storms have been published in parallel with this report. This report can be used as a starting point for understanding potential investment prioritization processes and investment options. This report is intended to improve utility resilience planning by supporting constructive dialogue among utilities, regulators, and other stakeholders.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗
DOE OSTI2024

Current Practices in Distribution Utility Resilience Planning for Hurricanes and Non-Winter Storms

This report is part of a series of hazard-focused case studies examining common practices in electric utility resilience planning. We use standard terminology defining resilience as the ability to anticipate, withstand, absorb, and recover from hazards that cause long duration outages. We distinguish between reliability and resilience using IEEE 1366-2022, which defines "major events" as "an event that exceeds reasonable design and/or operational limits of the electric power system." Resilience planning is focused on "major event days" and reliability planning is focused on non-major event days. Utility resilience plans are assessed according to common recommended resilience components that we have identified in existing resilience frameworks. The focus of this report is on hurricanes and severe storms in which the primary hazards are precipitation or high winds. We exclude winter storms with primary hazards of ice and extreme cold, as they are a unique set of hazards with different resilience considerations. Standalone reports focusing on wildfires and winter storms have been published in parallel with this report. This report can be used as a starting point for understanding potential investment prioritization processes and investment options. This report is intended to improve utility resilience planning by supporting constructive dialogue among utilities, regulators, and other stakeholders.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗
NASA NTRS2008

Exploration Supply Chain Simulation

The Exploration Supply Chain Simulation project was chartered by the NASA Exploration Systems Mission Directorate to develop a software tool, with proper data, to quantitatively analyze supply chains for future program planning. This tool is a discrete-event simulation that uses the basic supply chain concepts of planning, sourcing, making, delivering, and returning. This supply chain perspective is combined with other discrete or continuous simulation factors. Discrete resource events (such as launch or delivery reviews) are represented as organizational functional units. Continuous resources (such as civil service or contractor program functions) are defined as enabling functional units. Concepts of fixed and variable costs are included in the model to allow the discrete events to interact with cost calculations. The definition file is intrinsic to the model, but a blank start can be initiated at any time. The current definition file is an Orion Ares I crew launch vehicle. Parameters stretch from Kennedy Space Center across and into other program entities (Michaud Assembly Facility, Aliant Techsystems, Stennis Space Center, Johnson Space Center, etc.) though these will only gain detail as the file continues to evolve. The Orion Ares I file definition in the tool continues to evolve, and analysis from this tool is expected in 2008. This is the first application of such business-driven modeling to a NASA/government-- aerospace contractor endeavor.

Source record↗
DOE OSTI2014

Definition of Capabilities Needed for a Single Event Effects Test Facility

The Federal Aviation Administration (FAA) is contemplating new regulations mandating testing of the vulnerability of flight-critical avionics to single event effects (SEE). A limited number of high-energy neutron test facilities currently serve the SEE industrial and institutional research community. The FAA recognizes that existing facilities have insufficient test capacity to meet new demand from such mandates; it desires more flexible irradiation capabilities to test complete, large systems and would like capabilities to address greater concerns for thermal neutrons. For this reason, the FAA funded this study by Spallation Neutron Source (SNS) staff with the ultimate aim of developing options for SEE test facilities using high-energy neutrons at the SNS complex. After an investigation of current SEE test practices and assessment of future testing requirements, three concepts were identified covering a range of test functionality, neutron flux levels, and fidelity to the atmospheric neutron spectrum. The costs and times required to complete each facility were also estimated. SEE testing is generally performed by accelerating the event rate to a point where the effects are still dominated by single events and double event causes of failures are negligible. In practice, acceleration factors of as high as 10 6 are applicable for component testing, whereas for systems testing acceleration factors of 10 4 seem to be the upper limit. It is strongly desirable that the irradiation facility be tunable over a large range of high-energy neutron fluxes of 10 2 - 10 4 n/cm²/s for systems testing and from 10 4 - 10 7 n/cm²/s for components testing. The most capable, most flexible, and highest-test-capacity option is a new stand-alone target station named the High-Energy neutron Test Station (HETS). It is also the most expensive option, with a cost to complete of approximately $100 million. Dual test enclosures would allow for simultaneous testing activity effectively doubling overall test capacity per HETS operating hour. Using about 1 kilowatt (kW) of proton power extracted from the accelerator before injection in the accumulator ring, its operation would be unnoticeable by neutron scattering users at the SNS target station. The H beam laser stripping technique would allow for control of beam power on the HETS target independent from power delivered to the SNS. Large systems with frontal areas of up to 1 x 2 m² could be accommodated with integral high-energy flux values (above 10 megaelectron-volt, or MeV) to at most 10 4 n/cm²/s; components could also be tested with flux levels to at most 10 7 n/cm²/s on beam sizes of up to 0.2 x 0.2 m². Selectable moderating material and neutron filters would allow tailoring of the neutron spectrum to user demands; charged particle deflectors could be switched to allow or deflect protons, pions, and muons. It is estimated that HETS would take 5 years to complete after award of contract, including engineering design and construction. Commissioning would take at least another 6 months. Interference with SNS principal operations was not considered in the construction time estimate; connection of the proton transport line and tunnel from the accelerator high energy beam transport (HEBT) and construction around existing site utilities would require careful planning and coordination with beam operations at the SNS. A high-energy (HE) neutron test facility using an available beam line on the SNS target station is a technically and financially attractive option. Inspired by the new ChipIR instrument on the ISIS TS 2 spallation source in the UK, a similar facility could be placed on an unused beam line in the SNS instrument hall [e.g., on beam line 8 (both A and B channels would be needed) or on beam line 10]. The performance would approach that of an HETS (~80%), but it would be operationally more limited, with only a single user at a time. Space is more limited, so the maximum system size would be about half of that in an HETS. Flexibility to tailor the spectrum would be somewhat more limited. While this concept was not as fully developed and characterized, preliminary work indicates very high HE flux levels should be possible, with ample thermal neutrons as well. Flux control would be more difficult than at HETS because proton power on target be whatever the SNS was operating at for neutron scattering. Neutron attenuation devices would have to be employed with as-yet undetermined control resolution. However, no new buildings would be needed, and the necessary utilities are already present in the SNS Experiment Hall. The estimated cost for a beam line option is around $15 million; the time to complete would be 3 years after award of contract, plus at least 6 months for commissioning. Interference of construction activities with SNS operations should be negligible. This option would require negotiation with the Department of Energy Basic Energy Sciences (BES) office -- the primary stakeholder of SNS -- for an application outside the usual scope of neutron scattering sciences. Furthermore, these presently open beam lines are highly desirable locations for proposed neutron scattering instruments and obtaining one of them for an SEE test facility will come only with persuasive and timely arguments to SNS leadership and the DOE BES. The third option is a tunnel extension/target cave facility providing the most basic system-level irradiation capability with minimal flexibility. Again not as well developed a concept as HETS, it would use a laser-stripping technique like an HETS, redirecting protons to a tunnel similar to the initial HETS proton transport tunnel. Indeed, this concept is intended to be upgradable to a full HETS facility. Only a small fraction of a watt of proton power would be used in this basic configuration, though. An uncooled target and primitive shielding arrangement would provide beam on modestly sized systems that must be placed in close proximity to the target. The neutron fluence would be less uniform over the system than with the HETS or the beam line option. A data acquisition room and support area would be located on the ground level; access to the target cave would be via elevator and/or stairway. As a result of the required excavation, new tunnel construction, shielding, data acquisition building, utilities, and other items, the estimated cost is $30 million. The time to complete is expected be more than 3 years; here again construction interference with SNS operations has not been accounted for, but it could have a significant impact.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗
DOE OSTI2012

Critical Drivers for Safety Culture: Examining Department of Energy and U.S. Army Operational Experiences - 12382

Evaluating operational incidents can provide a window into the drivers most critical to establishing and maintaining a strong safety culture, thereby minimizing the potential project risk associated with safety incidents. By examining U.S. Department of Energy (DOE) versus U.S. Army drivers in terms of regulatory and contract requirements, programs implemented to address the requirements, and example case studies of operational events, a view of the elements most critical to making a positive influence on safety culture is presented. Four case studies are used in this evaluation; two from DOE and two from U.S. Army experiences. Although the standards guiding operations at these facilities are different, there are many similarities in the level of hazards, as well as the causes and the potential consequences of the events presented. Two of the incidents examined, one from a DOE operation and the other from a U.S. Army facility, resulted in workers receiving chemical burns. The remaining two incidents are similar in that significant conduct of operations failures occurred resulting in high-level radioactive waste (in the case of the DOE facility) or chemical agent (in the case of the Army facility) being transferred outside of engineering controls. A review of the investigation reports for all four events indicates the primary causes to be failures in work planning leading to ineffective hazard evaluation and control, lack of procedure adherence, and most importantly, lack of management oversight to effectively reinforce expectations for safe work planning and execution. DOE and Army safety programs are similar, and although there are some differences in contractual requirements, the expectations for safe performance are essentially the same. This analysis concludes that instilling a positive safety culture comes down to management leadership and engagement to (1) cultivate an environment that values a questioning attitude and (2) continually reinforce expectations for the appropriate level of rigor in work planning and procedure adherence. A review of the root causes and key contributing causes to the events indicate: - Three of the four root cause analyses cite lack of management engagement (oversight, involvement, ability to recognize issues, etc.) as a root cause to the events. - Two of the four root cause analyses cite work planning failures as a root cause to the events and all cause analyses reflect work planning failures as contributing factors to the events. - All events with the exception of the Tuba City plant shutdown indicate procedure noncompliance as a key contributor; in the case of Tuba City the procedure issues were primarily related to a lack of procedures, or a lack of sufficiently detailed procedures. - All events included discussion or suggestion of a lack of a questioning attitude, either on the part of management/supervision, work planners, or workers. This analysis suggests that the most critical drivers to safety culture are: - Management engagement, - Effective work planning and procedures, and - Procedure adherence with a questioning attitude to ensure procedural problems are identified and fixed. In high-hazard operational environments the importance of robust work planning processes and procedure adherence cannot be overstated. However, having the processes by themselves is not enough. Management must actively engage in expectation setting and ensure work planning that meets expectations for hazard analysis and control, develop a culture that encourages incident reporting and a questioning attitude, and routinely observe work performance to reinforce expectations for adherence to procedures/work control documents. In conclusion, the most critical driver to achieving a workforce culture that supports safe and effective project performance can be summarized as follows: 'Management engagement to continually reinforce expectations for work planning processes and procedure adherence in an environment that cultivates a questioning attitude'. (authors)

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗
DOE OSTI2013

Eliminating Inconsistencies in Simulation and Treatment Planning Orders in Radiation Therapy

Purpose: To identify deficiencies with simulation and treatment planning orders and to develop corrective measures to improve safety and quality. Methods and Materials: At Washington University, the DMAIIC formalism is used for process management, whereby the process is understood as comprising Define, Measure, Analyze, Improve, Implement, and Control activities. Two complementary tools were used to provide quantitative assessments: failure modes and effects analysis and reported event data. The events were classified by the user according to severity. The event rates (ie, number of events divided by the number of opportunities to generate an event) related to simulation and treatment plan orders were determined. Results: We analyzed event data from the period 2008-2009 to design an intelligent SIMulation and treatment PLanning Electronic (SIMPLE) order system. Before implementation of SIMPLE, event rates of 0.16 (420 of 2558) for a group of physicians that were subsequently used as a pilot group and 0.13 (787 of 6023) for all physicians were obtained. An interdisciplinary group evaluated and decided to replace the Microsoft Word-based form with a Web-based order system. This order system has mandatory fields and context-sensitive logic, an ability to create templates, and enables an automated process for communication of orders through an enterprise management system. After the implementation of the SIMPLE order, the event rate decreased to 0.09 (96 of 1001) for the pilot group and to 0.06 (145 of 2140) for all physicians (P<.0001). The average time to complete the SIMPLE form was 3 minutes, as compared with 7 minutes for the Word-based form. The number of severe events decreased from 10.7% (45 of 420) and 12.1% (96 of 787) to 6.2% (6 of 96) and 10.3% (15 of 145) for the pilot group and all physicians, respectively. Conclusions: There was a dramatic reduction in the total and the number of potentially severe events through use of the SIMPLE system. In addition, the order process has become more efficient and reliable.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
NASA NTRS2011

Kennedy Space Center Orion Processing Team Planning for Ground Operations

Topics in this presentation are: Constellation Ares I/Orion/Ground Ops Elements Orion Ground Operations Flow Orion Operations Planning Process and Toolset Overview, including: 1 Orion Concept of Operations by Phase 2 Ops Analysis Capabilities Overview 3 Operations Planning Evolution 4 Functional Flow Block Diagrams 5 Operations Timeline Development 6 Discrete Event Simulation (DES) Modeling 7 Ground Operations Planning Document Database (GOPDb) Using Operations Planning Tools for Operability Improvements includes: 1 Kaizen/Lean Events 2 Mockups 3 Human Factors Analysis

Letchworth, Gary↗
DOE OSTI2015

TU-CD-BRD-00: Incident Learning / RO-ILS

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

TU-CD-BRD-01: Making Incident Learning Practical and Useful: Challenges and Previous Experiences

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

TU-CD-BRD-02: Henry Ford Hospital System Experience, with Focus On Motivating and Reviewing

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

TU-CD-BRD-03: UCSD Experience, with Focus On Implementing Change

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

TU-CD-BRD-04: UCLA Experience, with Focus On Developing Metrics and Using RO-ILS

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2020

Physical and hydrodynamic properties of deep sea mining-generated, abyssal sediment plumes in the Clarion Clipperton Fracture Zone (eastern-central Pacific)

The anthropogenic impact of polymetallic nodule harvesting in the Clarion-Clipperton Fracture Zone is expected to strongly affect the benthic ecosystem. To predict the long-term, industrial-scale impact of nodule mining on the deep-sea environment and to improve the reliability of the sediment plume model, information about the specific characteristics of deep-sea particles is needed. Discharge simulations of mining-related fine-grained (median diameter ≈ 20 µm) sediment plumes at concentrations of 35–500 mg L –1 (dry weight) showed a propensity for rapid flocculation within 10 to 135 min, resulting in the formation of large aggregates up to 1100 µm in diameter. The results indicated that the discharge of elevated plume concentrations (500 mg L –1 ) under an increased shear rate (G ≥ 2.4 s –1 ) would result in improved efficiency of sediment flocculation. Furthermore, particle transport model results suggested that even under typical deep-sea flow conditions (G ≈ 0.1 s –1 ), rapid deposition of particles could be expected, which would restrict heavy sediment blanketing (several centimeters) to a smaller fall-out area near the source, unless subsequent flow events resuspended the sediments. Planning for in situ tests of these model projections is underway.

42 ENGINEERING↗
DOE OSTI2019

Alliance Project: Secure Control Systems for the Energy Sector

The Alliance Project addresses Area of Interest 4: Secure Remote Access for the Energy Sector, by combining physical and cyber access under one cybersecurity access system. The Alliance Project built on the successful completion of the Lemnos and Padlock Project (DOE-Funded Project started in 2007 and 2010) and researched and developed a solution for an Ethernet Security Gateway with the functionality required to integrate the physical access control cyber system and interface with legacy and new proximity card readers used for physical access requests. This project focused on securing and enhancing the cyber system the physical access control system operates on. The team tested and demonstrated the system solution on the SEL campus. Currently the physical access cyber system is completely separate from the cyber access control cyber system. With a single system industry benefits include: (1) Single system to learn and teach employees; (2) Single system that collects and alerts on logs and events simplifying incident response plans and NERC CIP compliance; (3) Unifies trust management to a single system reducing the potential errors in privilege escalation or revocation; (4) Provides a stronger cybersecurity platform the physical access control system operates on. Today they are mostly plain text protocols and little cyber awareness; (5) Integration of physical access awareness allows the cyber system to react and adjust. In some cases, the cyber access can be enhanced with authorized physical access and other cases the cyber access can be more restricted with unauthorized physical access; and (6) Enables the utility to establish as large or as small a physical access control system as they require. One example would be when a utility shares a substation with a neighbor utility and can’t rely on the substation door for the physical access control. The Alliance technology enables them to lock equipment racks simply with no scalability issues because it stands on the cyber security infrastructure which is already highly scalable.

24 POWER TRANSMISSION AND DISTRIBUTION↗
DOE OSTI2021

Position Papers for the ASCR Workshop on Cybersecurity and Privacy for Scientific Computing Ecosystems

At the request of the Department of Energy's (DOE) Office of Advanced Scientific Computing Research (ASCR), this program committee has been tasked with organizing a workshop to identify basic research needs in cybersecurity and privacy to better support DOE's science and energy mission. As part of the process, the program committee is soliciting community input in the form of position papers to help identify significant use cases, facility issues, and other barriers to enabling verifiably trustworthy computational science while preserving data confidentiality as appropriate for scientific workflows of interest to DOE. The program committee will review these position papers and based on the fit of their area of expertise and interest, selected contributors will have the opportunity to participate in the workshop currently planned as a virtual event November 3-5th, 2021. The thrust areas that will be explored by this workshop are the following: (1) Algorithms for secure, scalable, privacy-enhancing technologies and frameworks, including: Federated AI/ML, Differential privacy, Randomized algorithms, Adversarial modeling & simulation, Graph algorithms, and Formal methods; (2) Platforms to support the entire scientific-computing ecosystem, including edge computing for large-scale experiments, focusing on heterogeneous systems and distributed systems, including: Heterogeneous computing systems, Distributed computing systems, and Secure data architectures; and (3) Data workflows to allow agile use of data while preserving integrity and privacy, making the important properties verifiable either at runtime or post-computation, including: Integrity and provenance and Data management infrastructure. Topics that are out-of-scope for the workshop include discussing specific proposed solutions or areas that are clearly out of DOE's fundamental and applied-sciences mission scope, e.g., cryptography, enterprise security, and general-operations technology.

97 MATHEMATICS AND COMPUTING↗
DOE OSTI2025

InterGraph-CPS: A Graph-Theoretic Approach to Characterize Cross-Domain Cyber-Physical Interdependencies and Uncertainties in Electric Grid Systems for Improved Decision-Making in Operation and Response

Critical infrastructure systems such as the electric grid are increasingly cyber-physical; yet, despite the cyber-physical characteristics of critical infrastructure systems, the physical process system and communication/control network system are traditionally analyzed in siloes. As these systems become more cyber-physical, it is crucial that models and methods are available to assess the cyber physical system (CPS) interdependencies, characteristics, and event propagation for improved planning, operation, and response. Thus, we proposed an integrated structural and temporal CPS interdependency analysis framework, InterGraph-CPS, that provides insight into the CPS function during normal operation as well as disturbances. This integrated structural and temporal interdependency framework is uniquely designed for assessing CPSs by account for the challenges of analyzing cyber and physical data streams together due to data availability, data type, and time scale differences. By leveraging both structural (e.g., graph analysis) and temporal (e.g., data analytics) techniques, different CPS behaviors and configurations can be accounted for.

24 POWER TRANSMISSION AND DISTRIBUTION↗