scholarly journals System Failure: An Analysis of 2000 Incident Reports

1993 ◽  
Vol 21 (5) ◽  
pp. 684-695 ◽  
Author(s):  
W. B. Runciman ◽  
R. K. Webb ◽  
R. Lee ◽  
R. Holland
Keyword(s):  
Complex Systems ◽  
Human Factors ◽  
Human Error ◽  
Local Level ◽  
System Failure ◽  
International Agencies ◽  
Level Ii ◽  
Level I ◽  
Four Levels

Although 70–80% of problems have some component of human error, its overall contribution to many problems may be small; studies of complex systems have revealed that up to 85% are primarily due to deficiencies in the lay-out and processes of the system. The anaesthetist has to operate in a complex system; many problems originate from deficiencies in this system. Information of relevance to system failure was extracted from the first 2000 incidents reported to the Australian Incident Monitoring Study (AIMS). A system-based deficiency directly contributed to one-quarter of problems (four-fifths if human factors are included), some aspect of the system minimized the adverse outcome in over half of all cases (four-fifths if human factors are included), and in two-thirds (three-quarters if human factors are included) a system-based strategy would have been helpful; the system was implicated in 90% of all incidents (97% if human factors are included). Regardless of whether or not all human error should be regarded as part of the “system”, attempts to modify its incidence and nature have to emanate from the system. AIMS reporting pathways and the organizations involved in developing and implementing strategies to improve the system operate at four levels. Level I involves the use of AIMS reports by hospitals and group practices for audit at a local level. Level II involves AIMS participants sending forms to the AIMS central office; collated information is then sent back to contributors by newsletter. Level III involves interaction between AIMS and the major professional bodies and level IV interaction between AIMS, these bodies and a variety of national and international agencies. Over 100 topics were identified from the AIMS data for consideration at one or more of these levels. AIMS has the potential not only to play a vital practical role in the continued enhancement of the quality of anaesthetic practice, but also to provide a valuable resource for research at the increasingly important interface between human behaviour and complex systems.

Community quality of life. A case study of the new Popești Leordeni, Ilfov

2020 ◽  
Vol 31 (4) ◽  
pp. 335-361
Author(s):  
Andreea Acasandre
Keyword(s):  
Quality Of Life ◽  
Urban Sprawl ◽  
Public Transportation ◽  
Local Level ◽  
Residential Areas ◽  
Community Quality Of Life ◽  
Leisure Services ◽  
The People ◽  
Level I

This paper is concerned with the analysis of some worrying present tendencies of urban sprawl in the large, important economic centers of Romania. It focuses on the tendency of building new residential apartments on the outskirts of the big cities. Most of these developments target young people that belong to a still-developing middle class. Big problems emerge, however, when real estate investors take advantage of the buyers’ lack of experience and of the authorities’ poor management, offering small, badly-built apartments in new residential areas which are designed around only one function: housing. The absence of complementary functions that could support the development of communities gravely impairs the inhabitants’ quality of life. At the local level, I was able to identify two main problems: the absence of the necessary infrastructure to support such a massive increase in population, and the absence of local amenities. On a larger scale, the consequences are significant as well: chronic traffic jams due to the large number of people who commute to Bucharest daily, for work. Even though at first Popeşti-Leordeni (a satellite-town of Romania’s capital) was considered a good housing option, the people living there are rapidly becoming highly unsatisfied with their quality of life. In their opinion, the biggest problems of this urban area are the absence of green spaces, of leisure services, of parking options, and of means of public transportation. To these complaints, the inhabitants add dissatisfaction with the general problems caused by the endless building sites, which also represent one of the main causes for the lack of cleanliness, bad roads, noise and pollution plaguing the area. This paper, based both on the analysis of statistical data and on empirical research, aims to show that Popeşti-Leordeni, especially the New Popeşti neighborhood, is an example of bad housing caused by corruption, investors’ greed, bad management on the part of the authorities, and the young buyers’ inexperience. Keywords: quality of life; urban sprawl; satellite-town; mono-functionality; community.

scholarly journals Human Factors Analysis of Air Traffic Safety Based on HFACS-BN Model

2019 ◽  
Vol 9 (23) ◽  
pp. 5049 ◽  
Author(s):  
Tao Lyu ◽  
Wenbin Song ◽  
Ke Du
Keyword(s):  
Human Factors ◽  
Traffic Safety ◽  
Traffic Control ◽  
Human Error ◽  
Air Traffic ◽  
General Aviation ◽  
Objective Data ◽  
Factors Analysis ◽  
Four Levels ◽  
Human Factors Analysis

Air traffic control (ATC) performance is important to ensure flight safety and the sustainability of aviation growth. To better evaluate the performance of ATC, this paper introduces the HFACS-BN model (HFACS: Human factors analysis and classification system; BN: Bayesian network), which can be combined with the subjective information of relevant experts and the objective data of accident reports to obtain more accurate evaluation results. The human factors of ATC in this paper are derived from screening and analysis of 142 civil and general aviation accidents/incidents related to ATC human factors worldwide from 1980 to 2019, among which the most important 25 HFs are selected to construct the evaluation model. The authors designed and implemented a questionnaire survey based on the HFACS framework and collected valid data from 26 frontline air traffic controllers (ATCO) and experts related to ATC in 2019. Combining the responses with objective data, the noisy MAX model is used to calculate the conditional probability table. The results showed that, among the four levels of human factors, unsafe acts had the greatest influence on ATC Performance (79.4%), while preconditions for safe acts contributed the least (40.3%). The sensitivity analysis indicates the order of major human factors influencing the performance of ATC. Finally, this study contributes to the literature in terms of methodological development and expert empirical analysis, providing data support for human error management intervention of ATC in aviation safety.

scholarly journals ASPEK PENGETAHUAN DALAM TUTURAN BERTANYA GURU BAHASA INDONESIA DALAM PROSES PEMBELAJARANASPEK PENGETAHUAN DALAM TUTURAN BERTANYA GURU BAHASA INDONESIA DALAM PROSES PEMBELAJARAN

Diksi ◽  
2018 ◽  
Vol 25 (1) ◽  
Author(s):  
Guntur Sakti Dewangga
Keyword(s):  
Speech Act ◽  
High Order ◽  
Language Teachers ◽  
Analysis Techniques ◽  
Level Ii ◽  
Level I ◽  
Four Levels ◽  
Conceptual Question ◽  
Bahasa Indonesia ◽  
Low Order

Penelitian ini mengkaji masalah tentang aspek pengetahuan dalam tuturan bertanya guru bahasa Indonesia. Objek dalam penelitian ini adalah tuturan bertanya guru bahasa Indonesia dalam proses pembelajaran.Data dalam penelitian ini dianalisis dengan teknik analisis kualitatif. Dari hasil analisis ditemukan empat tingkatan/level aspek pengetahuan dalam tuturan bertanya guru bahasa Indonesia, yaitu level I-Low Order Convergent, level II-High Order Convergent, level III-Low Order Divergent, dan level IV-High Order Divergent. Hasil temuan tersebut menunjukkan bahwa dalam kegiatan pembelajaran banyak ditemukan tuturan tanya guru dengan tingkat/level I. Hal ini berarti tuturan tanya guru dalam proses pembelajaran banyak menggunakan tuturan dengan aspek pengetahuan yang sederhana atau rendah. Hasil analisis menunjukkan ada tiga temuan terkait konten/isi dalam tuturan bertanya guru bahasa Indonesia, yaitu pertanyaan konseptual, pertanyaan empiris, dan pertanyaan nilai. Dari ketiga isi tuturan bertanya tersebut, yang paling banyak muncul adalah tuturan bertanya konseptual. Hal tersebut dikarenakan dalam pembelajaran guru banyak mengajukan pertanyaan terkait konsep materi tertentu.Kata Kunci: aspek pengetahuan, konten, tuturan, tanya, pembelajaran KNOWLEDGE ASPECT OF INTERROGATIVE SPEECH OF INDONESIAN LANGUAGE TEACHERS IN TEACHING PROCESSES  ABSTRACTThis study aims knowledge aspect of interrogative speech of Indonesian language teachers. The objectwas interrogative speechs of Indonesian language teachers. The data was analyzed by content analysis techniques. Based on data analysis reaveals four levels of knowledge aspect in interrogative speech of Indonesian language teachers: level I-Low Order Convergent, level II-High Order Convergent, level III-Low Order Divergent, and level IV-High Order Divergent. The result reaveals that interrogative speech of Indonesian language teachers level I was most frequently used. It’s mean, the teachers used many interrogative speech level I or low knowledge aspect in teaching  processes.There are three contents of the interrogative speech act of Indonesian teachers in teaching processes: conceptual question, empirical question, and value question. Of the three contents of the question, the most frequently used is conceptual question, because in teaching the teachers ask more about the concept of a particular material.Keywords: knowledge aspect, content, speech, interrogative, teaching 

scholarly journals Congestion Evaluation of Pedestrians in Metro Stations Based on Normal-Cloud Theory

2019 ◽  
Vol 9 (17) ◽  
pp. 3624 ◽  
Author(s):  
Jibiao Zhou ◽  
Yao Wu ◽  
Xinhua Mao ◽  
Shun Guo ◽  
Minjie Zhang
Keyword(s):  
Video Data ◽  
Metro Station ◽  
Crowd Management ◽  
Level Ii ◽  
Level I ◽  
Four Levels ◽  
Cloud Theory ◽  
The City ◽  
Pedestrian Crowd

This study aims at evaluating the congestion level of pedestrians in metro stations. Twelve hours (4 h × three facilities) of video data were collected in the channel, stairway, and platform in a metro station in the city of Ningbo, China. The indicator of GPC (grade of pedestrian crowd) was proposed to quantify the congestion level of pedestrians. Four levels of congestion (level I, level II, level III, and level IV) were determined based on the GPC. A normal-cloud (NC) model was proposed and calibrated for the evaluation of three facilities including channel, stairway, and platform. The evaluation results showed that the GPC of L1-L2 and L2-L1 in channel are level II and level I, respectively. The GPC of upward and downward of stairway are level III and level I. The GPC of platform is level IV. Crowd management countermeasures were proposed for the management of pedestrians in metro station.

Human Error Assessment and Reduction Technique for Reducing the Number of Marine Accidents in Indonesia

2018 ◽  
Vol 874 ◽  
pp. 199-206 ◽  
Author(s):  
Ludfi Pratiwi Bowo ◽  
Masao Furusho
Keyword(s):  
Human Factors ◽  
Nuclear Power ◽  
Qualitative Method ◽  
Human Error ◽  
Reduction Technique ◽  
Error Assessment ◽  
Human Reliability Analysis ◽  
Marine Industry ◽  
Marine Accidents

Human factors is playing an important role in every accident, particularly marine accidents. Hence, a lot of researches were conducted to analyze the human factors involvement in the accidents. Since the development of marine industry shows progressively increasing nowadays, especially in Indonesia, as Indonesia vision to be a global maritime axis of the world for marine industry, the awareness of safety life at sea has to be increase as well. Human reliability analysis (HRA) consist of many methodologies to analyze the accidents, the basic steps of HRA is qualitative method and quantitative method, one of the HRA methodology is Human Error Assessment and Reduction Technique (HEART) methodology which has been established in 1982 to assess nuclear power plant. HEART methodology is applied in this study to analyze the cause of marine accidents by human factors. The aims of this study are to know the main cause of accidents by human factors, to increase the awareness of safety at sea especially, and furthermore to improve the quality of ergonomics at sea. There are 93 EPC which discovered in this study for analyzing marine accidents in Indonesia.

scholarly journals Paving the Path to Value: The Role of Registry Studies in Interventional Radiology

2018 ◽  
Vol 02 (02) ◽  
pp. 128-132
Author(s):  
Melinda Wang ◽  
Maureen Kohi
Keyword(s):  
Interventional Radiology ◽  
Evidence Based ◽  
Randomized Controlled ◽  
Level Ii ◽  
Complementary Role ◽  
Inadequate Sample Size ◽  
Level I ◽  
Based Medicine

AbstractThe growth rate of interventional radiology (IR) procedures and practitioners has exceeded the pace of evidence development to support evidence-based practice. In the innovative and highly adaptive field of IR, there exists a tremendous need for interventional radiologists to practice evidence-based medicine as a way to maintain and improve quality of health care. Randomized controlled trials (RCTs) are considered to be the gold standard of research, providing level I evidence, but in procedural subspecialties, they remain difficult to design and implement due to challenges in randomization, blinding, and inadequate sample size. To build the foundation of evidence in IR, registry studies can play a complementary role to RCTs. Clinical data registries may offer a more practical approach to gathering outcomes data, important in this era with the advent of the Medicare Access and CHIP Reauthorization Act (MACRA), in comparison with RCTs. Properly designed registries can store an abundance of data with which high-quality observational studies can be performed. Although considered level II evidence, these registry studies will allow the evaluation of both performance and value of IR procedures, particularly in circumstances in which an RCT would not be feasible. This manuscript aims to serve as a guide for developing and participating in IR registry studies.

E.H. Christopherson Lecture: Lessons for the United States From the Worldwide Child Survival Revolution

PEDIATRICS ◽  
1995 ◽  
Vol 96 (2) ◽  
pp. 342-346
Author(s):  
Carl E. Taylor
Keyword(s):  
United States ◽  
Social Development ◽  
Local Level ◽  
Action Learning ◽  
Child Survival ◽  
The United States ◽  
Childhood Immunization ◽  
International Agencies ◽  
The People

It is time to apply in the United States' principles that are emerging from a series of World Summits and United Nations Conferences on Children, Environment, Population, Women, and Social Development. After years of top-down programs supported by international agencies, which have made some significant contributions in promoting activities such as childhood immunization but are having problems of sustainability, we need to focus now on integrated human development. The past tendency in international assistance to concentrate on economic development has not helped the people in greatest need. There is growing realization that what improves the quality of life most is what people do for themselves. Sustainability requires social mobilization at the local level. There are thousands of integrated, social development projects around the world that demonstrate the power of community-based, participatory approaches and we know how such local programs can be made to work under any political or economic system. What we haven't learned is how to "go to scale" in extending such projects to cover larger populations. A promising approach11 seems to be using successful local projects upgraded into Centers for Action Learning to promote the adaptation of science-based innovations to everyday life in a whole region of a country.

A Phonemic Implicational Feature Hierarchy of Phonological Contrasts for English-Speaking Children

2005 ◽  
Vol 48 (4) ◽  
pp. 817-833 ◽  
Author(s):  
Stephanie F. Stokes ◽  
Thomas Klee ◽  
Cecyle Perry Carson ◽  
David Carson
Keyword(s):  
Computer Software ◽  
Phonological Development ◽  
Phonological Disorders ◽  
Relational Analysis ◽  
Level Ii ◽  
Recent Trends ◽  
English Speaking ◽  
Level I ◽  
Four Levels ◽  
Phonological Contrasts

Contrastive feature hierarchies have been developed and used for some time in depicting typical phonological development and in guiding therapy decisions. Previous descriptions of feature use have been based on independent analyses and usually phonetic inventories. However, recent trends in phonology include a relational analysis of phonemic inventories (D. Ingram & K. D. Ingram, 2001). The current investigation was a relational analysis of the phonemic inventories of 40 typically developing 2-year-old American-English-speaking children. Consonant inventories were derived from spontaneous speech samples using the Logical International Phonetics Programs computer software (D. K. Oller & R. E. Delgado, 1999). Cluster analysis was used to determine the grouping of contrastive features. Four levels emerged. Level I included [consonant], [sonorant], and [coronal], Level II included [voice], Level III included [anterior], [continuant], and [nasal], and Level IV included [lateral] and [strident]. Results suggested that the resulting 4-level phonemic feature hierarchy might be used to classify the phonological systems of children with phonological disorders.

scholarly journals Updates on the Clinical Evidenced Herb-Warfarin Interactions

2014 ◽  
Vol 2014 ◽  
pp. 1-18 ◽  
Author(s):  
Beikang Ge ◽  
Zhen Zhang ◽  
Zhong Zuo
Keyword(s):  
Red Clover ◽  
Clinical Findings ◽  
Warfarin Interaction ◽  
Therapeutic Window ◽  
General Mechanism ◽  
Clinical Effects ◽  
Multicenter Studies ◽  
Level Ii ◽  
Level I

Increasing and inadvertent use of herbs makes herb-drug interactions a focus of research. Concomitant use of warfarin, a highly efficacious oral anticoagulant, and herbs causes major safety concerns due to the narrow therapeutic window of warfarin. This paper presents an update overview of clinical findings regarding herb-warfarin interaction, highlighting clinical outcomes, severity of documented interactions, and quality of clinical evidence. Among thirty-eight herbs, Cannabis, Chamomile, Cranberry, Garlic, Ginkgo, Grapefruit, Lycium, Red clover, and St. John’s wort were evaluated to have major severity interaction with warfarin. Herbs were also classified on account of the likelihood of their supporting evidences for interaction. Four herbs were considered ashighly probableto interact with warfarin (level I), three were estimated asprobable(level II), and ten and twenty-one werepossible(level III) anddoubtful(level IV), respectively. The general mechanism of herb-warfarin interaction almost remains unknown, yet several pharmacokinetic and pharmacodynamic factors were estimated to influence the effectiveness of warfarin. Based on limited literature and information reported, we identified corresponding mechanisms of interactions for a small amount of “interacting herbs.” In summary, herb-warfarin interaction, especially the clinical effects of herbs on warfarin therapy should be further investigated through multicenter studies with larger sample sizes.

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