Results for “fault tree” — Page 10

DOE OSTI2023

On the Language of Reliability: A System Engineer Perspective

In its classical definition, risk is defined by three elements: what can go wrong, what are its consequences, and how likely is it to occur? While this definition makes sense in a regulatory-based framework where for the current fleet of operating light water reactors (LWRs), the risks associated with nuclear power plants typically are characterized in terms of core damage and large early release frequency (LERF), this approach does not provide a useful snapshot of the health of the plant from a broader perspective. This is due to the very narrow context in which the term “risk” typically is defined as nuclear safety aspects that have the potential to impact public health. In this paper, we take the viewpoint of nuclear safety that is reflective of the current fleet of operating LWRs for which core damage frequency and LERF are appropriate metrics. For other advanced reactor designs, other more applicable technology neutral metrics of reactor safety metrics would be specified. A possible alternate path would start by redefining the word risk with a broader meaning that better reflects the needs of a system health and asset management decision-making process. Rather than asking how likely an event could occur (in probabilistic terms), we can ask how far this event is from occurring. Our approach starts by defining and quantifying component and system health in terms of a “distance” between its actual and limiting conditions, i.e., determination of the margin that exists between the current state/condition and the state where the component/system is no longer capable of achieving its intended function. A margin is a measure that is more reflective of the current state or performance of a component, and therefore more closely tied to decisions that are made on an ongoing basis. Further, we will show how, given the data available from plant equipment reliability and monitoring (e.g., pump vibration data) and prognostic (e.g., component remaining useful life estimation) data, a margin can be described and determined for all types of maintenance approaches (e.g., corrective or predictive maintenance). We show how classical reliability models (e.g., fault trees) can be used to quantify the system margin provided component margin values. In the approach described in this paper, the propagation of margin values through classical reliability models are not performed using classical probabilistic calculations applied to sets (as performed in a typical plant probabilistic risk assessment). Instead, we show how it is possible to propagate margin values through Boolean logic gates (i.e., AND and OR operators) through distance-based operations.

97 MATHEMATICS AND COMPUTING↗

DOE OSTI2025

Development and Demonstration of a Prototype Molten Salt Sampling System

Molten salt reactors (MSRs) offer potential operability and safety advantages when compared to commercial light water reactors (LWRs). However, operating experience with MSRs is sparse in comparison to what exists for LWRs. Further, the chemical and isotopic composition of the fuel and/or coolant salt is dynamic and difficult to characterize continuously, posing potential safety, operability, and safeguards unknowns that need to be addressed. A molten salt sampling system (MSSS) is regarded as a necessary subsystem within first generation MSRs used to obtain samples of salt for chemical and isotopic analysis in support of the need to monitor and control salt composition during operation. The MSSS is being developed using the Safety-in-Design (SiD) methodology, which incorporates incremental integration of safety analysis into the design process. The MSSS conceptual design emerging from the application of the early stages of the SiD methodology consists of a sample collection system and its housing, a freeze port, and inert gas control and delivery systems. This article describes the prototypes developed to test the functions of these MSSS subsystems, presents the results of testing in both dry and molten salt environments (including reliability data collection performed in accordance with the principles of SiD and the development of a semiquantitative fault tree model), and summarizes the opportunities for future design and testing enhancements based on the results of prototype testing.

molten salt reactor↗

DOE OSTI2016

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for “intensity modulated radiation therapy (IMRT)” as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

TU-FG-201-12: Designing a Risk-Based Quality Assurance Program for a Newly Implemented Y-90 Microspheres Procedure

Purpose: To create a quality assurance program based upon a risk-based assessment of a newly implemented SirSpheres Y-90 procedure. Methods: A process map was created for a newly implemented SirSpheres procedure at a community hospital. The process map documented each step of this collaborative procedure, as well as the roles and responsibilities of each member. From the process map, different potential failure modes were determined as well as any current controls in place. From this list, a full failure mode and effects analysis (FMEA) was performed by grading each failure mode’s likelihood of occurrence, likelihood of detection, and potential severity. These numbers were then multiplied to compute the risk priority number (RPN) for each potential failure mode. Failure modes were then ranked based on their RPN. Additional controls were then added, with failure modes corresponding to the highest RPNs taking priority. Results: A process map was created that succinctly outlined each step in the SirSpheres procedure in its current implementation. From this, 72 potential failure modes were identified and ranked according to their associated RPN. Quality assurance controls and safety barriers were then added for failure modes associated with the highest risk being addressed first. Conclusion: A quality assurance program was created from a risk-based assessment of the SirSpheres process. Process mapping and FMEA were effective in identifying potential high-risk failure modes for this new procedure, which were prioritized for new quality assurance controls. TG 100 recommends the fault tree analysis methodology to design a comprehensive and effective QC/QM program, yet we found that by simply introducing additional safety barriers to address high RPN failure modes makes the whole process simpler and safer.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

WE-B-BRC-00: Concepts in Risk-Based Assessment

Prospective quality management techniques, long used by engineering and industry, have become a growing aspect of efforts to improve quality management and safety in healthcare. These techniques are of particular interest to medical physics as scope and complexity of clinical practice continue to grow, thus making the prescriptive methods we have used harder to apply and potentially less effective for our interconnected and highly complex healthcare enterprise, especially in imaging and radiation oncology. An essential part of most prospective methods is the need to assess the various risks associated with problems, failures, errors, and design flaws in our systems. We therefore begin with an overview of risk assessment methodologies used in healthcare and industry and discuss their strengths and weaknesses. The rationale for use of process mapping, failure modes and effects analysis (FMEA) and fault tree analysis (FTA) by TG-100 will be described, as well as suggestions for the way forward. This is followed by discussion of radiation oncology specific risk assessment strategies and issues, including the TG-100 effort to evaluate IMRT and other ways to think about risk in the context of radiotherapy. Incident learning systems, local as well as the ASTRO/AAPM ROILS system, can also be useful in the risk assessment process. Finally, risk in the context of medical imaging will be discussed. Radiation (and other) safety considerations, as well as lack of quality and certainty all contribute to the potential risks associated with suboptimal imaging. The goal of this session is to summarize a wide variety of risk analysis methods and issues to give the medical physicist access to tools which can better define risks (and their importance) which we work to mitigate with both prescriptive and prospective risk-based quality management methods. Learning Objectives: Description of risk assessment methodologies used in healthcare and industry Discussion of radiation oncology-specific risk assessment strategies and issues Evaluation of risk in the context of medical imaging and image quality E. Samei: Research grants from Siemens and GE.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

WE-B-BRC-01: Current Methodologies in Risk Assessment

Prospective quality management techniques, long used by engineering and industry, have become a growing aspect of efforts to improve quality management and safety in healthcare. These techniques are of particular interest to medical physics as scope and complexity of clinical practice continue to grow, thus making the prescriptive methods we have used harder to apply and potentially less effective for our interconnected and highly complex healthcare enterprise, especially in imaging and radiation oncology. An essential part of most prospective methods is the need to assess the various risks associated with problems, failures, errors, and design flaws in our systems. We therefore begin with an overview of risk assessment methodologies used in healthcare and industry and discuss their strengths and weaknesses. The rationale for use of process mapping, failure modes and effects analysis (FMEA) and fault tree analysis (FTA) by TG-100 will be described, as well as suggestions for the way forward. This is followed by discussion of radiation oncology specific risk assessment strategies and issues, including the TG-100 effort to evaluate IMRT and other ways to think about risk in the context of radiotherapy. Incident learning systems, local as well as the ASTRO/AAPM ROILS system, can also be useful in the risk assessment process. Finally, risk in the context of medical imaging will be discussed. Radiation (and other) safety considerations, as well as lack of quality and certainty all contribute to the potential risks associated with suboptimal imaging. The goal of this session is to summarize a wide variety of risk analysis methods and issues to give the medical physicist access to tools which can better define risks (and their importance) which we work to mitigate with both prescriptive and prospective risk-based quality management methods. Learning Objectives: Description of risk assessment methodologies used in healthcare and industry Discussion of radiation oncology-specific risk assessment strategies and issues Evaluation of risk in the context of medical imaging and image quality E. Samei: Research grants from Siemens and GE.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

WE-B-BRC-02: Risk Analysis and Incident Learning

Prospective quality management techniques, long used by engineering and industry, have become a growing aspect of efforts to improve quality management and safety in healthcare. These techniques are of particular interest to medical physics as scope and complexity of clinical practice continue to grow, thus making the prescriptive methods we have used harder to apply and potentially less effective for our interconnected and highly complex healthcare enterprise, especially in imaging and radiation oncology. An essential part of most prospective methods is the need to assess the various risks associated with problems, failures, errors, and design flaws in our systems. We therefore begin with an overview of risk assessment methodologies used in healthcare and industry and discuss their strengths and weaknesses. The rationale for use of process mapping, failure modes and effects analysis (FMEA) and fault tree analysis (FTA) by TG-100 will be described, as well as suggestions for the way forward. This is followed by discussion of radiation oncology specific risk assessment strategies and issues, including the TG-100 effort to evaluate IMRT and other ways to think about risk in the context of radiotherapy. Incident learning systems, local as well as the ASTRO/AAPM ROILS system, can also be useful in the risk assessment process. Finally, risk in the context of medical imaging will be discussed. Radiation (and other) safety considerations, as well as lack of quality and certainty all contribute to the potential risks associated with suboptimal imaging. The goal of this session is to summarize a wide variety of risk analysis methods and issues to give the medical physicist access to tools which can better define risks (and their importance) which we work to mitigate with both prescriptive and prospective risk-based quality management methods. Learning Objectives: Description of risk assessment methodologies used in healthcare and industry Discussion of radiation oncology-specific risk assessment strategies and issues Evaluation of risk in the context of medical imaging and image quality E. Samei: Research grants from Siemens and GE.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2016

WE-B-BRC-03: Risk in the Context of Medical Imaging

Prospective quality management techniques, long used by engineering and industry, have become a growing aspect of efforts to improve quality management and safety in healthcare. These techniques are of particular interest to medical physics as scope and complexity of clinical practice continue to grow, thus making the prescriptive methods we have used harder to apply and potentially less effective for our interconnected and highly complex healthcare enterprise, especially in imaging and radiation oncology. An essential part of most prospective methods is the need to assess the various risks associated with problems, failures, errors, and design flaws in our systems. We therefore begin with an overview of risk assessment methodologies used in healthcare and industry and discuss their strengths and weaknesses. The rationale for use of process mapping, failure modes and effects analysis (FMEA) and fault tree analysis (FTA) by TG-100 will be described, as well as suggestions for the way forward. This is followed by discussion of radiation oncology specific risk assessment strategies and issues, including the TG-100 effort to evaluate IMRT and other ways to think about risk in the context of radiotherapy. Incident learning systems, local as well as the ASTRO/AAPM ROILS system, can also be useful in the risk assessment process. Finally, risk in the context of medical imaging will be discussed. Radiation (and other) safety considerations, as well as lack of quality and certainty all contribute to the potential risks associated with suboptimal imaging. The goal of this session is to summarize a wide variety of risk analysis methods and issues to give the medical physicist access to tools which can better define risks (and their importance) which we work to mitigate with both prescriptive and prospective risk-based quality management methods. Learning Objectives: Description of risk assessment methodologies used in healthcare and industry Discussion of radiation oncology-specific risk assessment strategies and issues Evaluation of risk in the context of medical imaging and image quality E. Samei: Research grants from Siemens and GE.

60 APPLIED LIFE SCIENCES↗

DOE OSTI2020

Safety Risk Reliability Model Library

SR2ML is a software package which contains a set of safety and reliability models designed to be interfaced with the INL developed RAVEN code. These models can be employed to perform both static and dynamic system risk analysis and determine risk importance of specific elements of the considered system. Two classes of reliability models have been developed; the first class includes all classical reliability models (Fault-Trees, Event-Trees, Markov models and Reliability Block Diagrams) which have been extended to deal not only with Boolean logic values but also time dependent values. The second class includes several components aging models. Models of these two classes are designed to be included in a RAVEN ensemble model to perform time dependent system reliability analysis (dynamic analysis). Similarly, these models can be interfaced with system analysis codes to determine failure time of systems and evaluate accident progression (static analysis).

Wang, Congjian↗

DOE OSTI2021

Event-modeled Risk Assessment Using Linked Diagrams

Event Modeling Risk Assessment using Linked Diagrams (EMRALD) is a software tool developed at INL for researching the capabilities of dynamic PRA (Probabilistic Risk Assessment). In order to promote the effective use of dynamic PRA by the general community, EMRALD focuses on the following key aspects: Simplifying the modeling process by providing a structure that corresponds to traditional PRA modeling methods Providing a user interface (UI) that makes it easy for the user to model and visualize complex interactions Allowing the user to couple with other analysis applications such as physics based simulations. This includes one-way communication for most applications and two-way loose coupling for customizable applications Providing the sequence and timing of events that lead to the specified outcomes when calculating results Traditional aspects of components with basic events, fault trees, and event trees are all captured in a dynamic framework of state diagrams, which are displayed.

Prescott, SteveR↗

DOE OSTI2018

West Texas A&M University Pantex Internship Final Report: How to Apply RCM MENG-4097

This summer internship here at Pantex pertained to how one may approach equipment and apply Reliability Centered Maintenance. Reliability Centered Maintenance (RCM), is a strategy for maintenance first used in the 1960’s. Within this strategy there are three methods of maintenance, preventative, run-till-failure, and condition based and these will be what a part may be categorized into. When approaching equipment/parts to decide which category they fall into they must go under a five procedures, Criticality, Fault Tree Analysis, Task Analysis, Effectiveness, and Cost. The pilot project was to test the maintenance strategies on the preventative maintenance [PM’s] work orders used on Air Handling Units (AHU) and Dehumidifying Units (DHU) here at the Pantex Plant. This was accomplished by making recommendations on the preventative maintenance work orders.

99 GENERAL AND MISCELLANEOUS↗

DOE OSTI2016

Macro Supply Chain Lifecycle Decision Analytics

This report summarizes a two-year LDRD project that investigated the problem of representing complex supply chains, identifying the worst risks and evaluating mitigation options. Our team developed a framework that includes a representation for business processes, risk assessment questions, risk indicators and methods for analyzing and summarizing the data. In our approach, the Process Matrix represents an overall supply chain for an end product in a high-level, tabular form. It connects the various touch-points of a business process including people, external vendors, tools, storage locations and transportation services while capturing the flow of both physical and intellectual artifacts. We believe these direct connections are exactly the things that a process owner can typically control. These material flows (both physical and intellectual) are also represented in a graph. This enables us to use graph-oriented analysis such as fault tree analysis and attack graph generation. Our approach is top-down, which helps users to get a more holistic understanding for a given amount of resources. Understanding the provenance of materials is difficult and it is easy to exhaust the analysts' resources. Rather than a tool to do vendor analysis or product comparison, our framework enables an enterprise-level analysis. The risk assessment questionnaires have a varying levels of detail and cover various aspects of the supply chain such as process steps, artifacts, suppliers, etc. and connections between these aspects such as artifact-storage, artifact-supplier, etc. Each question is further associated with one of seven risk indicators which can be used to summarize the risk. These risk indicators can also be weighted to reflect a user's concerns. We have successfully applied our framework to several use cases in various stages of its development and provided valuable insights to our partners, but it can also be applied to other complex systems outside of the supply chain security problem.

29 ENERGY PLANNING, POLICY, AND ECONOMY↗

DOE OSTI2019

A Reliability Study on the ALERTUS Emergency Management Notification System

Sandia National Laboratories conducted a reliability analysis on the Alertus mass notification system to determine if improvements need to be made to the system to increase reliability. The Alertus mass notification system for Building 803 was analyzed with a set number of components. The components, their associated failure modes and failure mode rates were inputted into a fault tree in the SAPHIRE software which calculated the reliability of the system to be 0.998269.

97 MATHEMATICS AND COMPUTING↗

DOE OSTI2021

Reliability Prediction using FMEA, FTA, and Related Techniques [Slides]

Summary: We presented a reliability analysis framework. We made point estimates of reliability using reliability block diagrams, fault trees, success trees and estimates with uncertainty using expert elicitation, Monte Carlo simulation, Bayesian analysis. Expert elicitation of failure modes and probabilities is labor-intensive, but critical. Bayesian analysis updates information from expert elicitation with data from reliability and aging tests (aging/compatibility data are needed to estimate lower-bound reliabilities at end of life). Estimation by more than one method helps insure consistency and accuracy.

97 MATHEMATICS AND COMPUTING↗

DOE OSTI2022

Weapon Systems Risk-Assessment Tool Review

To anticipate, and potentially mitigate, future problems in aging weapon systems, four unique riskassessment techniques were analyzed, including root-cause analysis tools, six-sigma problemsolving approaches, and lean six-sigma tools. Identifying the most efficient process, or tool, is crucial for successful application to current and future weapon systems, subsystems, and components. The following processes were reviewed: Fault Tree Analysis, Failure Modes and Effects Analysis, Bow-Tie Analysis, and Hazard and Operability Study. A systematic assessment was performed to determine the most desirable method, and included investigating qualitative versus quantitative characteristics, scope, process durations, advantages, and limitations. Presented results will outline the study findings and further illustrate a capacity to identify future issues and/or concerns, and ultimately, reduce risk.

45 MILITARY TECHNOLOGY, WEAPONRY, AND NATIONAL DEF↗

DOE OSTI2017

Reliability Study: On-Site Electrical System, 1998-2015

This report documents an analysis of the reliability of on-site electrical systems at U.S. commercial nuclear plants during the period 1998-2015. The study contains both individual component studies and system studies. The component studies are focused on key electrical components including circuit breakers, battery chargers, buses, batteries, and transformers. Data from the range of 1998 to 2015 were gathered, reviewed, and statistically evaluated for impacts on reliability as a function of relevant parameters: manufacturer, system, operating environment, inspection/testing regimen, operating range (voltages, amperes), setpoints, and other factors. The system studies identify seven operating nuclear power plants/units that represent different designs of offsite power sources and interconnecting power circuit paths, develop electrical single line diagrams and detailed fault tree models for the representing designs, and evaluate the electrical system reliability using the reliability data obtained from the component studies.

99 GENERAL AND MISCELLANEOUS↗

DOE OSTI2025

As part of its commitment to advancing safety and reliability assessment methodologies, Argonne National Laboratory pioneered the use of an evaluation method called the Success Path Method (SPM) to improve risk management for offshore oil and gas operations. The development of the SPM at Argonne has been driven by the need to improve existing risk assessment methodologies by focusing on the steps necessary for success rather than failure modes alone. This is particularly important for industrial environments like offshore facilities that perform multiple functions under a continuously evolving set of operational conditions – such as water depth and temperature, currents, and weather conditions. In these dynamic environments, the traditional Probabilistic Risk Assessment (PRA) approach is far too complex as it focuses on what can go wrong – which comprises an infinite failure space that must be fully explored and understood. By shifting the focus to a finite space of success paths, the SPM enables operators and decision makers to prioritize a manageable number of steps that must go right to ensure success. Building on its five decades of experience in safety assessments for the nuclear industry, Argonne made major adaptations to existing risk assessment methods utilizing features similar to fault trees that are traditionally used in PRA to map all pathways in which the system can malfunction. In contrast, SPM identifies the components and processes that must function correctly to achieve specific outcomes – such as preventing the uncontrolled release of hydrocarbons during drilling operations. The SPM framework integrates equipment, procedures, software, processes, and human actions to ensure that physical barriers meet critical safety functions in dynamic operational conditions. This approach helps identify failure modes and improve operational risk management by narrowing the focus to key success elements, which in turn reduces uncertainty and helps users understand, manage, and respond to failures.

97 MATHEMATICS AND COMPUTING↗

DOE OSTI2025

Quantitative Risk Assessment for Fuel Cell Electric Bus Hydrogen Storage and Refueling Facility

It is necessary to understand the safety implications and risk mitigation options for fuel cell electric bus fleet deployment, especially for related facilities responsible for operations such as production, storage, compression, and dispensing of hydrogen for use by the buses. In this report, we present a quantitative risk assessment for a potential fuel cell electric bus fleet that was motivated by efforts to improve resilience at the Portland International Airport but can be applicable to a range of hydrogen case studies and use cases. We estimated risk for a facility that produces, stores, compresses, and dispenses hydrogen for the fleet of buses, with a focus on individual risk to people in terms of annual frequency of fatality. We considered the frequency of hydrogen leaks that could result in harmful physical outcomes like jet fires or explosions, and the consequences of those outcomes for people. We created customized fault trees to calculate the frequencies of different sizes of leaks and event sequence diagrams to calculate ignition probabilities for the various leak sizes. We also leveraged the HyRAM+ toolkit to use these inputs to calculate overall risk for the facility, which we separated into one section responsible for producing, storing, and compressing hydrogen, and one section responsible for dispensing the hydrogen to the buses. We found that the dispensing area seemed to have a higher risk than the production/storage/compression area of the facility, largely because of the inclusion of a component with a high leak frequency (the heat exchanger used to cool the hydrogen before entering the vehicle, to prevent overheating and expansion of hydrogen in the onboard tank). For the example production and refueling facility we evaluated and the data we used for the analysis, the leak frequency had a larger impact on the risk differences between the two sections on the facility, compared to the physical outcome consequence, which was slightly different due to the varying fuel conditions, but not substantially different. Actions can be taken to prevent these hazards (e.g., lowering leak frequencies in system components) or to mitigate the consequences if they do occur (e.g., installing barriers to protect people if ignition events occur). The choice of which actions to take depends not only on safety considerations but also on space, time, staffing, feasibility, and financial constraints. Therefore, the quantitative risk assessment approach can help understand relative risk contributions from different components, leak sizes, consequences, and human actions, to prioritize risk reduction strategies and balance these parameters. The outcomes of this report may be useful for a variety of stakeholders working in the hydrogen, transportation, vehicle, and aviation sector, including those responsible for aspects like facility design, operations, and regulations. There is not a single value of risk that determines whether a hypothetical system is “safe” or not. The insights about risk mitigations may be leveraged, and the quantitative risk assessment approach can be applied to other case studies to understand risk priorities and contributions specific to different FCEB and hydrogen facility uses.

08 HYDROGEN↗