Human error analysis: Review of past accidents and implications for improving robustness of system design

Since the establishment of the high-technology industry and industrial systems, developments of new materials and fabrication techniques, associated with cutting-edge structural and engineering assessments, are contributing to more reliable and consistent systems, thus reducing the likelihood of losses. However, recent accidents are acknowledged to be linked to human factors which led to catastrophic consequences. Therefore, the understanding of human behavioural characteristics interlaced with the actual technology aspects and organisational context is of paramount importance for the safety & reliability field. This study first approaches this multidisciplinary problem by classifying and reviewing 200 major accident data from insurance companies and regulatory authorities under the Cognitive Reliability and Error Analysis framework. Then, specific attention is dedicated to discuss the implications for improving robustness of system design and tackling the surrounding factors and tendencies that could lead to the manifestation of human errors

Learning from accidents: Investigating the genesis of human errors in multi-attribute settings to improve the organisation of design

Remarkable advances in engineering and system controls in recent times and the consequent development of state-of-the-art technologies are clearly resulting in economic, environmental and safety benefits to the society. Latest disasters, however, put human error in the glare of the media spotlight. The February 2016 train collision in southern Bavaria, Germany, which took 11 lives and left more than 90 people injured, is one of several examples where human errors appear to have played a significant role in a major accident. In this emblematic case, the railway system had multiple safety barriers in place, such as an automatic braking system if a train crosses a stop signal, but the track controller had reportedly disabled it. When he realised the error and tried to warn the drivers, it was too late (BBC, 2016)

Learning from major accidents to improve system design

© 2015 Elsevier Ltd.Despite the massive developments in new technologies, materials and industrial systems, notably supported by advanced structural and risk control assessments, recent major accidents are challenging the practicality and effectiveness of risk control measures designed to improve reliability and reduce the likelihood of losses. Contemporary investigations of accidents occurred in high-technology systems highlighted the connection between human-related issues and major events, which led to catastrophic consequences. Consequently, the understanding of human behavioural characteristics interlaced with current technology aspects and organisational context seems to be of paramount importance for the safety & reliability field. First, significant drawbacks related to the human performance data collection will be minimised by the development of a novel industrial accidents dataset, the Multi-attribute Technological Accidents Dataset (MATA-D), which groups 238 major accidents from different industrial backgrounds and classifies them under a common framework (the Contextual Control Model used as basis for the Cognitive Reliability and Error Analysis Method). The accidents collection and the detailed interpretation will provide a rich data source, enabling the usage of integrated information to generate input to design improvement schemes. Then, implications to improve robustness of system design and tackle the surrounding factors and tendencies that could lead to the manifestation of human errors will be effectively addressed

Tuning ZnO nanorods photoluminescence through atmospheric plasma treatments

Room temperature atmospheric plasma treatments are widely used to activate and control chemical functionalities at surfaces. Here, we investigated the effect of atmospheric pressure plasma jet (APPJ) treatments in reducing atmosphere (Ar/1 parts per thousand H-2 mixture) on the photoluminescence (PL) properties of single crystal ZnO nanorods (NRs) grown through hydrothermal synthesis on fluorine-doped tin oxide glass substrates. The results were compared with a standard annealing process in air at 300 degrees C. Steady-state photoluminescence showed strong suppression of the defect emission in ZnO NRs for both plasma and thermal treatments. On the other side, the APPJ process induced an increase in PL quantum efficiency (QE), while the annealing does not show any improvement. The QE in the plasma treated samples was mainly determined by the near band-edge emission, which increased 5-6 fold compared to the as-prepared samples. This behavior suggests that the quenching of the defect emission is related to the substitution of hydrogen probably in zinc vacancies (V-Zn), while the enhancement of UV emission is due to doping originated by interstitial hydrogen (H-i), which diffuses out during annealing. Our results demonstrate that atmospheric pressure plasma can induce a similar hydrogen doping as ordinarily used vacuum processes and highlight that the APPJ treatments are not limited to the surfaces but can lead to subsurface modifications. APPJ processes at room temperature and under ambient air conditions are stable, convenient, and efficient methods, compared to thermal treatments to improve the optical and surface properties of ZnO NRs, and remarkably increase the efficiency of UV emission. (c) 2019 Author(s). All article content, except where otherwise noted, is licensed under a Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/)

Derivative based global sensitivity measures

The method of derivative based global sensitivity measures (DGSM) has recently become popular among practitioners. It has a strong link with the Morris screening method and Sobol' sensitivity indices and has several advantages over them. DGSM are very easy to implement and evaluate numerically. The computational time required for numerical evaluation of DGSM is generally much lower than that for estimation of Sobol' sensitivity indices. This paper presents a survey of recent advances in DGSM concerning lower and upper bounds on the values of Sobol' total sensitivity indices $S\_{i}^{tot}$. Using these bounds it is possible in most cases to get a good practical estimation of the values of $S\_{i}^{tot}$. Several examples are used to illustrate an application of DGSM

A novel plasma jet with RF and HF coupled electrodes

In order to achieve low processing temperature and efficient coatings deposition for manufacturing applications, a novel torch has been developed that couples in a double DBD design high frequency (HF ~17 kHz) and radio frequency (RF ~27 MHz) excitations. The design allows to obtain a stable RF plasma also in reactive processes and with the possibility to control on the treated substrates ions flux and surface charging, avoiding the micro-discharges. The plasma has been electrically and optically characterized by emission spectroscopy

Liquid biopsy for rectal cancer: a systematic review

Background: The management of locally advanced rectal cancer (RC) is an evolving clinical field where the multidisciplinary approach can reach its best, and liquid biopsy for obtaining tumor-derived component such as circulating tumor DNA (ctDNA) might provide complementary informations. Methods: A systematic review of studies available in literature of liquid biopsy in non-metastatic RC has been performed according to PRISMA criteria to assess the role of ctDNA as a diagnostic, predictive and prognostic biomarker in this setting. Results: Twenty-five publications have been retrieved, of which 8 full-text articles, 7 abstracts and 10 clinical trials. Results have been categorized into three groups: diagnostic, predictive and prognostic. Few but promising data are available about the use of liquid biopsy for early diagnosis of RC, with the main limitation of sensitivity due to low concentrations of ctDNA in this setting. In terms of prediction of response to chemoradiation, still inconclusive data are available about the utility of a pre-treatment liquid biopsy, whereas some studies report a positive correlation with a dynamic (pre/post-treatment) monitoring. The presence of minimal residual disease by ctDNA was consistently associated with worse prognosis across studies. Conclusions: The use of liquid biopsy for monitoring response to chemoradiation and assess the risk of disease recurrence are the most advanced potential applications for liquid biopsy in RC, with implications also in the context of non-operative management strategies

Building capacity to provide innovative interventions for early psychosis in mental health professionals

Abstract Despite international guidelines, cognitive behavioural therapy for early psychosis (CBTep) is still under-used in daily clinical practice, mainly due to the lack of specific skills among mental health professionals. The aim of the study was to evaluate the feasibility and efficacy of a CBTep training course and to investigate the impact of trainees' variables on the level of skills acquisition. An intensive and graded CBTep training programme consisting of 112 hours of plenary lectures, 30 hours of group supervision and 3 months of practical training was offered to mental health professionals of 65 Italian community Mental Health Centers (CMHCs). CBT expert psychologists were used as the comparison group. Participants underwent pre-planned exams to test the level of skills acquisition and were requested to complete a satisfaction survey. The vast majority of participants (93%) completed the training with medium–high evaluation scores and reported to be highly satisfied with the course. CMHCs staff members achieved high scores in the examinations and no major differences between them and CBT expert psychologists were found in most of the final exam scores. Our results support the feasibility and the efficacy of the training to build specific CBTep capacity in a large cohort of professionals working in Italian Generalist Mental Health Services. Key learning aims (1) To understand the capacity building of a short training programme in CBT for early psychosis dedicated to community mental health professionals. (2) To consider the optimal characteristics of a CBT training programme for early psychosis. (3) To reflect on the feasibility of a CBT training programme for early psychosis in the context of Italian Community Mental Health Services