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  2004


Title: Design of a safer approach to intravenous drug infusions: failure mode effects analysis

Source: QUALITY & SAFETY IN HEALTH CARE

Author: Apkon, M; Leonard, J; Probst, L; DeLizio, L; Vitale, R

Year: 2004

Abstract: Objectives: A set of standard processes was developed for delivering continuous drug infusions in order to improve ( 1) patient safety; ( 2) efficiency in staff workflow; ( 3) hemodynamic stability during infusion changes, and ( 4) efficient use of resources. Failure modes effects analysis (FMEA) was used to examine the impact of process changes on the reliability of delivering drug infusions. Setting: An 11 bed multidisciplinary pediatric ICU in the children's hospital of an academic medical center staffed by board certified pediatric intensivists. The hospital uses computerized physician order entry for all medication orders. Methods: A multidisciplinary team characterized key elements of the drug infusion process. The process was enhanced to increase overall reliability and the original and revised processes were compared using FMEA. Resource consumption was estimated by reviewing purchasing and pharmacy records for the calendar year after full implementation of the revised process. Staff satisfaction was evaluated using an anonymous questionnaire administered to staff nurses in the ICU and pediatric residents who had rotated through the ICU. Results: The original process was characterized by six elements: selecting the drug; selecting a dose; selecting an infusion rate; calculating and ordering the infusion; preparing the infusion; programming the infusion pump and delivering the infusion. The following practice changes were introduced: standardizing formulations for all infusions; developing database driven calculators; extending infusion hang times from 24 to 72 hours; changing from bedside preparation by nurses to pharmacy prepared or premanufactured solutions. FMEA showed that the last three elements of the original process had high risk priority numbers (RPNs) of >225 whereas the revised process had no elements with RPNs >100. The combined effect of prolonging infusion hang times, preparation in the pharmacy, and purchasing premanufactured solutions resulted in 1500 fewer infusions prepared by nurses per year. Nursing staff expressed a significant preference and pediatric residents unanimously expressed a strong preference for the revised process. Conclusions: Standardization of infusion delivery reduced the frequency for completing the most unreliable elements of the process and reduced the riskiness of the individual elements. Both contribute to a safer system.


Title: Reliability improvement of a diesel engine using the FMETA approach

Source: QUALITY AND RELIABILITY ENGINEERING INTERNATIONAL

Author: Arcidiacono, G; Campatelli, G

Year: 2004

Abstract: This paper provides a way to deal with issues related to design for reliability using axiomatic design (AD). A theoretical approach is studied, starting from the traditional theory of AD, in order to help designers to optimize the product's reliability using a structured approach. The aim of this work is to introduce a new method that is able to assess the product reliability using the support of the AD methodology combined with other methods, e.g. FMEA and FTA. The approach developed is called failure mode and effect tree analysis (FMETA). FMETA allows the designer to find the most critical characteristic of the product from a reliability point of view and provides the designer with a set of possible changes. The core of this work is the development of a reliability tree, used to evaluate both the RPN for the component of the product and to find the reliability relation useful for the following optimization. The reliability tree is born from the combined use of AD, FMEA and FTA. This method has been validated by an application to an automotive heavy-duty diesel engine. Copyright (C) 2004 John Wiley Sons, Ltd.


Title: Failure mode identification through clustering analysis

Source: QUALITY AND RELIABILITY ENGINEERING INTERNATIONAL

Author: Arunajadai, SG; Uder, SJ; Stone, RB; Tumer, IY

Year: 2004

Abstract: Research has shown that nearly 80% of the costs and problems associated with product design are created during product development, and cost and quality are essentially designed into products during the conceptual design stage. Failure identification procedures (such as failure modes and effects analysis (FMEA), failure modes, effects and criticality analysis (FMECA) and fault tree analysis (FTA)) and design of experiments are currently being used for both quality control and for the detection of potential failure modes during the design stage or post-product launch. Although all of these methods have their own advantages, they do not provide the designer with an indication of the predominant failures that should receive considerable attention while the product is being designed. The work presented here proposes a statistical clustering procedure to identify potential failures in the conceptual design stage. A functional approach, which hypothesizes that similarities exist between different failure modes based on the functionality of the product/component, is employed to identify failure modes. The various steps of the methodology are illustrated using a hypothetical design example. Copyright (C) 2004 John Wiley Sons, Ltd.


Title: Sneak path analysis

Source: INTECH

Author: Baybutt, P

Year: 2004

Abstract:


Title: Expanded FMEA (EFMEA)

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Bluvband, Z; Grabov, P; Nakar, O

Year: 2004

Abstract: The main FMEA objective is the identification of ways in which a product, process or service fail to meet critical customer requirements, as well as the ranking and prioritization of the relative risks associated with specified failures. The effectiveness of prioritization can be significantly improved by using a simple graphical tool, as described by the authors. Evaluation of the adequacy of correction actions proposed to improve product/process/service, and the prioritization of these actions, can be supported by implementing the procedure proposed here, which is based on the evaluation of correction action feasibility. The procedure supports evaluation of both the feasibility of a corrective action implementation and impact of the action taken on failure mode.


Title: Analyzing reliability - A simple yet rigorous approach

Source: IEEE TRANSACTIONS ON INDUSTRY APPLICATIONS

Author: Bono, R; Alexander, R; Dorman, A; Kim, YJ; Reisdorf, J

Year: 2004

Abstract: Reliability of the electrical power system is a critical factor for continuous process operations. This paper presents an analytical method for determining distribution system reliability that can be easily implemented to form a basis for plant improvement studies. The paper demonstrates the implementation of the Failure Modes and Effects Analysis and Fault Tree Analysis techniques based on the IEEE Gold Book. The analysis provides a basis for informed decisions when selecting systems designed to increase system availability. The analytical techniques are illustrated using two simple distribution schemes and-it is shown how the,techniques may be applied to systems that are more complex.


Title: Evaluation of uncertainties related to passive systems performance

Source: NUCLEAR ENGINEERING AND DESIGN

Author: Burgazzi, L

Year: 2004

Abstract: A methodological and structured procedure to address the uncertainties related to passive safety functions is presented. The matter is treated with reference to a passive system designed for decay heat removal of advanced light water reactors, relying on natural circulation and provided with a heat exchanger immersed in a cooling pool, acting as heat sink, and connected to the pressure vessel via steam and condensate main lines. Two hazard identification used qualitative methods, as failure mode and effect analysis (FMEA) and hazard and operability study (HAZOP), are utilized and the relative results compared in order to assess the main sources of physical failure. The identification of the sources of uncertainties related to passive system performance, in terms of parameters which drive the failure mechanisms, follows. Finally the uncertainties are evaluated both for their assessment in probabilistic terms and for the determination of most contributors to the system thermal-hydraulic response. (C) 2004 Elsevier B.V. All rights reserved.


Title: Failure modes analysis of organizational artefacts that protect systems

Source: PROCEEDINGS OF THE INSTITUTION OF MECHANICAL ENGINEERS PART B-JOURNAL OF ENGINEERING MANUFACTURE

Author: Busby, JS; Hibberd, RE; Mileham, AR; Mullineux, G

Year: 2004

Abstract: Designed systems inevitably rely to some degree for their protection on organizational artefacts. These are rules, procedures, instructions, authority structures and so on that are designed, like physical devices, but have organizational rather than physical functions. An analysis was conducted of maritime accidents to investigate how these, organizational artefacts were implicated in failure, and a method was then developed to help system designers to perform a failure modes analysis of these artefacts. The proposal is that analyses of failure modes in physical devices should be accompanied by parallel analysis of failure modes in organizational artefacts.


Title: How to avoid the generation of logic loops in the construction of fault trees

Source: RELIABILITY ENGINEERING & SYSTEM SAFETY

Author: Demichela, M; Piccinini, N; Ciarambino, I; Contini, S

Year: 2004

Abstract: Generation of an infinite series of identical sub-trees may occur during the construction of a Fault Tree (FT) when one item of equipment in a plant is considered several times in the same sub-tree in the course of the tree extraction from a HazOp (Hazard Operability analysis) analysis. Generation of loops in the construction of an FT can be avoided by means of an ad hoc logical analysis in which certain simple rules of syntax are taken into account. A radical solution. however, can be obtained if identification of unwanted events in a process plant is not undertaken with conventional procedures. such as HazOp (Operability Analysis with guide words, failure mode and effect analysis (FMEA) etc.), but with a more modern and structured version. such as Recursive Operability Analysis (ROA), which is both systematic and complete, and allows direct extraction of logic trees. (FT. event trees, etc.) for subsequent quantification. This feature means that, by contrast with conventional operability analysis, the congruence of the ROA itself can be checked. The ROA method is illustrated in this paper with the aid of some simple examples. (C) 2003 Elsevier Ltd. All rights reserved.


Title: Safety analysis on steam turbine protection system based on FMEA and grey relation analysis

Source: PROGRESS IN SAFETY SCIENCE AND TECHNOLOGY, VOL 4, PTS A and B

Author: Dong, YL; Gu, YJ; Yang, K

Year: 2004

Abstract: Aimed at overcoming the low precision problem of traditional failure mode and effects analysis (FNMA), a method of quantitative safety analysis based on 171 FMEA and grey relation analysis is propose. In the method, the advantage of grey theory in solving problem with part known information is used and the precision of safety analysis is improved. It is applied to analyze the safety of steam turbine protection system, the familiar failure modes and relevant components are ranked by their risk priority. It is shown by the instance that the method is feasible and effective. And it can be used as a powerful support for taking effective measures to improve the safety of protection system.


Title: Failure mode effect analysis applied to the use of infusion pumps

Source: PROCEEDINGS OF THE 26TH ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY, VOLS 1-7

Author: Fechter, RJ; Barba, JJ

Year: 2004

Abstract: Failure Mode Effect Analysis (FMEA) offers a prospective approach to reducing the risk associated with health care delivery. Beginning in February, 2002, an interdisciplinary team of fifteen individuals, including end-users, conducted an FMEA for the use of infusion pumps at UCSF Medical Center. The use of infusion pumps was identified as the area of highest risk, based on incident report data. The team identified sixteen potential failure modes, including their potential effects and causes, and assigned a risk priority number to each based on the potential severity, probability, and detectability of the failure. Notable failure modes included: incorrect programming; improper or inconsistent labeling of solution, tubing, and pump; potential use of malfunctioning or damaged pumps; and incorrect programming by nurses related to device design. The team then broke into smaller work groups and invited more end-users to perform root cause analyses and suggest recommended actions/outcome measures for each failure mode with a risk priority number of 32 or higher (on our scale of 1 to 64). Finally, the FMEA team assembled all of the data, prepared a final report, and assigned responsibility for key recommended actions.


Title: Effects analysis fuzzy inference system in nuclear problems using approximate reasoning

Source: ANNALS OF NUCLEAR ENERGY

Author: Guimaraes, ACF; Lapa, CMF

Year: 2004

Abstract: In this paper a fuzzy inference system modeling technique applied on failure mode and effects analysis (FMEA) is introduced in reactor nuclear problems. This method uses the concept of a pure fuzzy logic system to treat the traditional FMEA parameters: probabilities of occurrence, severity and detection. The auxiliary feed-water system of a typical two-loop pressurized water reactor (PWR) was used as practical example in this analysis. The kernel result is the conceptual confrontation among the traditional risk priority number (RPN) and the fuzzy risk priority number (FRPN) obtained from experts opinion. The set of results demonstrated the great potential of the inference system and advantage of the gray approach in this class of problems. (C) 2003 Elsevier Ltd. All rights reserved.


Title: Fuzzy FMEA applied to PWR chemical and Volume Control System

Source: PROGRESS IN NUCLEAR ENERGY

Author: Guimaraes, ACF; Lapa, CMF

Year: 2004

Abstract: In this paper, a fuzzy inference system (FIS) modeling technique is introduced to treat a nuclear reliability engineering problem. This method uses the concept of a pure fuzzy logic system where the fuzzy rule base consists of a collection of fuzzy IF-THEN rules. The fuzzy inference engine uses these fuzzy IF-THEN rules to determine a mapping of the input universe of discourse over the output universe of discourse based on fuzzy logic principles. The risk priority number (RPN) (typical of a traditional Failure Mode & Effects Analysis - FMEA) is calculated and compared to fuzzy risk priority number (FRPN), obtained by the use of the scores from expert opinion. These scores are opinions about probabilities of Occurrence, Severity and not Detection of a failure of the studied system. The Chemical and Volume Control System was adopt as practical example in the study of case. The results demonstrated the potential of the inference system to this problem class. (C) 2004 Elsevier Ltd. All rights reserved.


Title: Software safety analysis: Using the entire risk analysis toolkit

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Guthrie, VH; Parikh, PB

Year: 2004

Abstract: When an accident occurs, it is common to attribute the accident to a failure in the system. Therefore, precautions must be taken to design the system to provide safeguards that will support the system even when failures occur. The problem, however, is that accidents occur where there is no failure in the system (i.e., the software, hardware, and humans "work" as they are supposed to). The flaw is in the design oversight for specific high-risk situations. It is up to the decision maker to: Ensure that adequate design and safety checks have been performed before the system is put into operation Ensure that a comprehensive risk analysis is conducted to examine both the design element malfunctions and the design oversights to determine the loss sequences Be satisfied that the loss sequences are understood with adequate confidence that the system risk is at or below the risk acceptance criteria


Title: A new ranking method for fuzzy FMEA

Source: APPLICATIONS AND SCIENCE IN SOFT COMPUTING

Author: Hitam, MS; Gobee, S; Subari, K

Year: 2004

Abstract: In this paper, we extend the method introduced by Bowles and Palaez (1995) for the risk ranking in Failure Mode and Effect Analysis (FMEA). This method called as multi-ranking method allows combination of both the quantitative method (numeric ranking and fuzzy number) and the qualitative method (linguistic ranking) to be employed in the ranking of risk. It employs two types of aggregation method namely an input ranking aggregation and an output ranking aggregation method. Experimental investigations were carried out in actual industrial environment on a paste printing process of printed circuit board at Motorola, Penang, Malaysia. Comparisons were made between traditional FMEA Risk Priority Number (RPN) risk ranking and the newly proposed method. The results show that the use of both the qaulitative and quantitave information in the risk ranking could provides almost similar outcomes with that of the Fuzzy FMEA.


Title: Investigation of improving MEMS type VOA's reliability

Source: RELIABILITY, TESTING AND CHARACTERIZATION OF MEMS/MOEMS III

Author: Hong, SK; Lee, YG; Park, MY

Year: 2004

Abstract: MEMS technologies have been applied to a lot of areas, such as optical communications, Gyroscopes and Bio-medical components and so on. In terms of the applications in the optical communication field, MEMS technologies are essential, especially, in multi dimensional optical switches and Variable Optical Attenuators(VOAs). This paper describes the process for the development of MEMS type VOAs with good optical performance and improved reliability. Generally, MEMS VOAs have been fabricated by silicon micro-machining process, precise fibre alignment and sophisticated packaging process. Because, it is composed of many structures with various materials, it is difficult to make devices reliable. We have developed MEMS type VOSs with many failure mode considerations (FMEA: Failure Mode Effect Analysis) in the initial design step, predicted critical failure factors and revised the design, and confirmed the reliability by preliminary test. These predicted failure factors were moisture, bonding strength of the wire, which wired between the MEMS chip and TO-CAN and instability of supplied signals. Statistical quality control tools (ANOVA, T-test and so on) were used to control these potential failure factors and produce optimum manufacturing conditions. To sum up, we have successfully developed reliable MEMS type VOAs with good optical performances by controlling potential failure factors and using statistical quality control tools. As a result, developed VOAs passed international reliability standards (Telcodia GR-1221-CORE).


Title: A knowledge-based methodology for designing reliable multi-agent systems

Source: AGENT-ORIENTED SOFTWARE ENGINEERING IV

Author: Klein, M

Year: 2004

Abstract: Multi-agent systems must be able to operate robustly despite many possible failure modes ('exceptions') that can occur. Traditionally, multi-agent system (MAS) designers have largely relied on their experience and intuition in order to anticipate all the ways their systems can fail, and how these problems can best be addressed. While methodologies such as failure mode effects analysis (FMEA) do exist [1], they simply provide a systematic procedure for analyzing systems, without offering specific insights into what exceptions can occur or how they can be resolved. This approach is becoming untenable, however, as the scale, heterogeneity and openness of multi-agent systems increases. Multi-agent systems, with their promise of self-organized behavior, are being looked to as a way to smoothly and rapidly integrate the activities of large collections of software entities that may never have worked together before. The agents in such 'open' contexts will not have been designed under centralized control, and must operate on the infrastructures at hand. Such systems must be able to operate effectively despite a bewildering range of possible exceptions. We have identified two main classes of exceptions that can occur in MAS contexts: Commitment Violations: This category consists of problems where some entities in the MAS do not properly discharge their commitments to each other, e.g. when a subcontractor is overdue with a task, a message is delivered garbled or late, or a host computer crashes. Even the best production code includes an average of 3 design faults per 1000 lines of code [2], and in open systems we can expect a wide range of code quality as well as actively malicious agents. Emergent Dysfunctions: This category consist of dysfunctional behaviors that emerge from the locally correct behavior of many agents. There are many examples of such dysfunctions, ranging from social dilemmas such as the (C) Springer-Verlag Berlin Heidelberg 2004.


Title: Scenario-based failure modes and effects analysis using expected cost

Source: JOURNAL OF MECHANICAL DESIGN

Author: Kmenta, S; Ishii, K

Year: 2004

Abstract: Failure modes and effects analysis (FMEA) uses the product of three ranked factors to compute the risk priority number (RPN). Unfortunately, the RPN components have ambiguous definitions, and multiplying ranked values is not a valid operation. As a result, the RPN produces inconsistent risk priorities. In addition, FMEA uses distinct analyses for each system level and life cycle phase, making it difficult to consolidate interrelated risk information. The goal of scenario-based FMEA is to delineate and evaluate risk events more accurately. Probability and cost provide a consistent basis for risk analysis and decision making, and failure scenarios provide continuity across system levels and life cycle phases.


Title: An improved Failure Mode Effects Analysis for hospitals

Source: ARCHIVES OF PATHOLOGY & LABORATORY MEDICINE

Author: Krouwer, JS

Year: 2004

Abstract: Objective.-To review the Failure Mode Effects Analysis (FMEA) process recommended by the Joint Commission on Accreditation of Health Organizations and to review alternatives. This reliability engineering tool may be unfamiliar to hospital personnel. Data Sources.-Joint Commission on Accreditation of Health Organizations recommendations, Mil-Std-1629A, and other articles about FMEA were used. Study Selection.-The articles were selected by a literature search that included Web site-accessible material. Data Extraction.-All articles found were used. Data Synthesis.-The results are based on the articles cited and the author's experience in conducting FMEAs in the medical diagnostics industry. Conclusions.-Fault trees and a list of quality system essentials are recommended additions to the FMEA process to help identify failure mode effects and causes. Neglecting mitigations for failure modes that have never occurred is a possible danger when too much emphasis is placed on improving risk priority numbers. A modified Pareto, not based on the risk priority number, is recommended when there are qualitatively different failure mode effects with different severities. Performing a FMEA that both meets accreditation requirements and reduces the risk of medical errors is an attainable goal, but it may require a different focus.


Title: Fault detection in systems - A fuzzy approach

Source: DEFENCE SCIENCE JOURNAL

Author: Kumar, A; Karmakar, G

Year: 2004

Abstract: The task of fault detection is important when dealing with failures of crucial nature. After detection of faults in a system, it is advisable to suggest maintenance action before occurrence of a failure. Fault detection may be done by observing various symptoms of the system during its operational stage. Sometimes, symptoms cannot be quantified easily but can be expressed in linguistic terms. Since linguistic terms are fuzzy quantifiers, these can be represented by fuzzy numbers. In this paper, two cases have been discussed, where a fault likely to affect a particular system/systems, is detected. In the first case, this is done by means of a compositional rule of inference. The second case is based on modified similarity measure. For both these cases, linguistic terms have been expressed as trapezoidal fuzzy numbers.


Title: Risk analysis for fail-safe motion control implementation in surgical robotics

Source: Robotics: Trends, Principles and Applications, Vol 15

Author: Munoz, VF; Garcia-Morales, I; Fernandez-Lozano, J; Gomez-De-Gabriel, JM; Garcia-Cerezo, A; Vara, C

Year: 2004

Abstract: This paper describes the design and implementation of a motion control architecture for the robotic assistant ERM (Endoscopic Robotic Manipulator), developed by the authors for handling the camera in laparoscopic surgery. The system provides the direct control of the camera positioning inside the abdominal cavity, by means of surgeon voice commands. This motion controller is implemented on a fail-safe architecture, designed from a Failure Mode Effect Analysis (FMEA). The system has been tested by means of experimentation with live animals.


Title: Failure modes and effects analysis during design of computer software

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Ozarin, N

Year: 2004

Abstract: Performing FMEA on computer software presents problems and challenges not found in FMEA of electronic hardware. Contractual directions are usually very limited or nonexistent, leaving the analyst to establish and tailor guidelines needed for a particular analysis. Where code is unavailable or off limits to the analysis, the FMEA is of limited usefulness but can still contribute to a more reliable system design. Unfortunately, many reliability analysts will have more difficulty developing an approach to software analysis than doing it. An understanding of the software design process and a discussion of various approaches to software design FMEA is presented to make development of an appropriate approach and performance of the analysis itself easier to understand. Moving from the lowest level of analysis to the highest level - typically from the method level to the module or package level - a FMEA becomes less accurate, less precise, and less informative, while the process becomes less difficult, less tedious, and less time-consuming. Moving from the lowest level of analysis to the highest also means a FMEA is based increasingly on the stated intent of the software designers and less on the actual product behavior. For any analysis above the code level, the analyst's conclusions about effects at each level will unfortunately be no better than the descriptions that the software designers provide.


Title: Systematic approach to the planning and execution of product remanufacture

Source: PROCEEDINGS OF THE INSTITUTION OF MECHANICAL ENGINEERS PART E-JOURNAL OF PROCESS MECHANICAL ENGINEERING

Author: Parkinson, HJ; Thompson, G

Year: 2004

Abstract: The challenge of remanufacturing is the production of quality products from returned discarded cores of unknown quality. Case studies and published literature reveal that there are no established processes tailored to the particular needs of product remanufacture. This paper outlines the difficulties associated with the planning and execution of product remanufacture. It then presents a systematic approach for the planning and execution of product remanufacture based upon the failure mode and effect analysis (FMEA) method. The approach is demonstrated in case studies of the remanufacture of an air-conditioning unit and a turbocharger. The results from the case studies are discussed and conclusions are drawn. The wider issues associated with remanufacturing including reliability and safety, further research opportunities and the design of functional products are then discussed and conclusions drawn.


Title: Comparison study of electromagnet and permanent magnet systems for an accelerator using cost-based failure modes and effects analysis

Source: IEEE TRANSACTIONS ON APPLIED SUPERCONDUCTIVITY

Author: Spencer, CM; Rhee, SJ

Year: 2004

Abstract: The next generation of particle accelerators will be one-of-a-kind facilities, and to meet their luminosity goals they must have guaranteed availability over their several decade lifetimes. The Next Linear Collider (NLC) is one viable option for a 1 TeV electron-positron linear collider, it has an 85% overall availability goal. We previously showed how a traditional Failure Modes and Effects Analysis (FMEA) of a SLAC electromagnet leads to reliability-enhancing design changes. Traditional FMEA identifies failure modes with high risk but does not consider the consequences in terms of cost, which could lead to unnecessarily expensive components. We have used a new methodology, "Life Cost-Based FMEA," which measures risk of failure in terms of cost, in order to evaluate and compare two different technologies that might be used for the 8653 NLC magnets: electromagnets or permanent magnets. The availabilities for the two different types of magnet systems have been estimated using empirical data from SLAC's accelerator failure database plus expert opinion on permanent magnet failure modes and industry standard failure data. Labor and material costs to repair magnet failures are predicted using a Monte Carlo simulation of all possible magnet failures over a 30-year lifetime. Our goal is to maximize up-time of the NLC through magnet design improvements and the optimal combination of electromagnets and permanent magnets, while reducing magnet system lifecycle costs.


Title: Models of behavior deviations in model-based systems

Source: ECAI 2004: 16TH EUROPEAN CONFERENCE ON ARTIFICIAL INTELLIGENCE, PROCEEDINGS

Author: Struss, P

Year: 2004

Abstract: Tasks like diagnosis, failure-modes-and-effects analysis (FMEA), and therapy proposal involve reasoning about variables and parameters deviating from some reference state. In model-based systems, one tries to capture this kind of inferences by models that describe how such deviations are emerging and propagated through a system. Several techniques and systems have been developed that address this issue, in particular in the area of qualitative modeling. However, to our knowledge, a rigorous mathematical foundation and a "recipe" for how to construct such compositional deviation models has not been presented in the literature, despite the widespread use of the idea and the techniques. In this paper, we present a general mathematical formalization of deviation models. Based on this, aspects of constructing libraries of deviation models, their properties, and their application in consistency-based diagnosis and prediction-based FMEA in a component-oriented framework are analyzed.


Title: Failure modes and effects analysis through knowledge modelling

Source: JOURNAL OF MATERIALS PROCESSING TECHNOLOGY

Author: Teoh, PC; Case, K

Year: 2004

Abstract: Failure mode and effect analysis (FMEA) is a widely used quality improvement and risk assessment tool in manufacturing. Accumulated information about design and process failures recorded through FMEA provides very valuable knowledge for future product and process design. However, the way the knowledge is captured poses considerable difficulties for reuse. This research aims to contribute to the reuse of FMEA knowledge through a knowledge modelling approach. An attempt is made to shift FMEA activities to the conceptual design stage. The early warning about possible failures will enable designers to avoid costly and difficult design changes at later stages of the design process. An object-oriented approach has been used to create an FMEA model. Functional diagrams have been used for the conceptual model. The FMEA model is assisted by functional reasoning techniques to enable automatic FMEA generation from historical data. The reasoning technique also provides a means for the creation of new knowledge. The FMEA generation process has been discussed. The automatic generation replaces the traditional brainstorming process for FMEA report creation. Failure report is used as the data source for the FMEA generation. The proposed method has been evaluated with a prototype software and case studies. (C) 2004 Published by Elsevier B.V.


Title: Modelling and reasoning for failure modes and effects analysis generation

Source: PROCEEDINGS OF THE INSTITUTION OF MECHANICAL ENGINEERS PART B-JOURNAL OF ENGINEERING MANUFACTURE

Author: Teoh, PC; Case, K

Year: 2004

Abstract: Failure modes and effects analysis (FMEA) is a quality improvement and risk assessment tool commonly used in industry. It is a living document used to capture design and process failure information. However, the traditional FMEA has its limitations in terms of knowledge capture and reuse. In order to increase its effectiveness, much research has been carried out to find an effective way to provide FMEA generation. However, because of the complexity of the information needed, most of the research concentrates on the application for a specific design domain. This paper reviews various FMEA research studies and modelling and reasoning methods that can be used for generic applications. A new proposal made is based on the 'knowledge fragment' reasoning concept suggested by Kato, Shirakawa and Hori in 2002. FMEA is introduced in the conceptual design stage so as to minimize the risks of costly failure. The method enables new knowledge to be formed using the limited available information in the conceptual design stage. A prototype has been created to evaluate the proposed method. Case studies have been conducted to validate the proposed method. The case studies show that the method is able to provide reliable results with limited information.


Title: Criticality analysis of process systems

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Thomaidis, TV; Pistikopoulos, S

Year: 2004

Abstract: This paper presents a systematic methodology for formal criticality analysis of process systems, which properly accounts for process interactions, equipment failure, stochastic process variations and events related to process safety. Important extensions are also presented for the use of such criticality analysis tools for safety and maintenance considerations. In the first part a quantitative measure for estimating the expected level for critical operations of process systems is introduced. Next a systematic algorithm of rating the equipment or events according to an associated criticality index is presented, coupled with a methodology for condition based maintenance for enhancing overall system efficiency and safety. The developed tools and the algorithms are demonstrated via a realistic case study of a compressor system, where (FOR) and (COR) are properly identified for the operable states. The proposed methodology is applied in order to rank the critical parts of the equipment or events, and then to result in the maintenance policy which fulfill certain efficiency and safety targets. While the criticality analysis methodology developed in this work predicts variable information regarding the overall system expected critical operations, the relative importance of the equipment to the process and identification of process and/or reliability bottlenecks, its link to the design optimization algorithm has not been formally established. However, as it is shown via the case study, the proposed methodology could be an efficient tool for the proper balance of preventive and condition based maintenance activities and the prediction of their impact to process operational decisions.


Title: Software intensive systems safety analysis

Source: IEEE AEROSPACE AND ELECTRONIC SYSTEMS MAGAZINE

Author: Tribble, AC; Miller, SP

Year: 2004

Abstract: Two important elements in the avionics suite of modern aircraft are: the Flight Control System (FCS) and the Flight Management System (FMS). The FCS provides the capability to stabilize and control the aircraft, while the FMS is responsible for flight planning and navigation. A clear trend in the aerospace industry is to place greater reliance on software systems, and many FCS and FMS subsystems are implemented primarily in software. For example, within the FCS is the Flight Guidance System (FGS) that generates roll and pitch guidance commands. Similarly, within the FMS is the Vertical Navigation (VNAV) function that acts like a third crew member in the cockpit, ordering mode change requests and resetting target altitude values to enable the aircraft to track the vertical flight plan. We have developed formal, executable models of the requirements for the mode logic of a FGS and for portions of the VNAV functionality. We have also conducted a comprehensive software safety analysis on the FGS mode logic model, and are completing the analysis of the VNAV model. This analysis uses as its starting point several "traditional" safety analysis techniques such as a Functional Hazard Assessment (FHA), a Fault Tree Analysis (FTA), and a Failure Mode Effects Analysis (FMEA). However, we are also using formal methods techniques known as model checking and theorem proving to verify the presence of safety properties in the model. This paper summarizes the (now completed) safety analysis that was performed on the FGS model, and highlights the similarities and differences with the (still on-going) safety analysis of the FMS model. In particular, we summarize progress made to date in the use of formal methods to verify the presence of the required safety properties in the models themselves.


Title: System Safety Integrity Level analysis and simulation for subsea valves

Source: PROGRESS IN SAFETY SCIENCE AND TECHNOLOGY, VOL 4, PTS A and B

Author: Tse, JYK; Wong, CK

Year: 2004

Abstract: Safety Integrity Level (SIL) is becoming an important criteria(s) for acceptance. for safety within the industry and this paper address system life cycle framework and the numerical simulation that relate to a High Integrity Pressure Protection System (HIPPS) Subsea Valve. The framework was based on the, international standard IEC 61508 and IEC 615 11 that provide the structure requirements relating to specification, design, integration, operation, maintenance, modification and decommissioning of a Safety Instrumented System (SIS). Simulation analysis of the SIS includes detailed Failure Mode and Effect Analysis (FMEA) leading to Fault Tree Analysis with logic table for each of the four cases: Safe Detected, Safe Undetected, Dangerous Detected and Dangerous Undetected. These safety analyses were based on the methodology within the IEC 61508, providing a structured verification process and the results were used to validate the HIPPS in compliance with Safety Integrity Level (SIL) 3 requirements. HIPPS is systems which are currently installed on the Subsea production system as a secondary barrier to prevent high pressure in the flowlines and risers.


Title: Application of telecom planar lightwave circuits for Homeland Security sensing

Source: CHEMICAL AND BIOLOGICAL POINT SENSORS FOR HOMELAND DEFENSE

Author: Veldhuis, G; Elders, J; van Weerden, H; Amersfoort, M

Year: 2004

Abstract: Over the past decade, a massive effort has been made in the development of planar lightwave circuits (PLCs) for application in optical telecommunications. Major advances have been made, on both the technological and functional performance front. Highly sophisticated software tools that are used to tailor designs to required functional performance support these developments. In addition extensive know-how in the field of packaging, testing, and failure mode and effects analysis (FMEA) has been built up in the struggle for meeting the stringent Telcordia requirements that apply to telecom products. As an example, silica-on-silicon is now a mature technology available at several industrial foundries around the world, where, on the performance front, the arrayed-waveguide grating (AWG) has evolved into an off-the-shelf product. The field of optical chemical-biological (CB) sensors for homeland security application can greatly benefit from the advances as described above. In this paper we discuss the currently available technologies, device concepts, and modeling tools that have emerged from the telecommunications arena and that can effectively be applied to the field of homeland security. Using this profound telecom knowledge base, standard telecom components can readily be tailored for detecting CB agents. Designs for telecom components aim at complete isolation from the environment to exclude impact of environmental parameters on optical performance. For sensing applications, the optical path must be exposed to the measurand, in this area additional development is required beyond what has already been achieved in telecom development. We have tackled this problem, and are now in a position to apply standard telecom components for CB sensing. As an example, the application of an AWG as a refractometer is demonstrated, and its performance evaluated.


Title: Driving the feedback loop reliability and safety in the full life cycle

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Whaling, KM; Kemp, DC

Year: 2004

Abstract: This paper describes a cohesive, integrated full life cycle product reliability and safety management process and an electronic database tool to facilitate the process. This system a) collects field failure data b) tracks/drives corrective actions c) pulls the lessons learned from the corrective actions d) places those lessons learned in the proactive analysis tools used in product development e) drives product development to use the proactive analysis tools f) keeps a library of proactive analyses to act as guides for future development g) provides the proactive analysis for direct use by a root cause team driving to analyze and correct a field failure h) tracks and drives all activities - allowing instant summary "dashboards" or "scorecards" to be created. Proactive and Reactive records are stored coincidently in a single database system - allowing real-time feedback. Reactive case resolution teams can tap into the development analyses or development teams can incorporate all relevant lessons learned from reactive case resolutions. All tools are attached to the database - to drive consistant usage and facilitate the integration of analysis libraries. All activities are mapped to a business process with pre-specified milestones and tracked to target dates - making this a real-time product reliability and safety management tool. Each record instantly becomes an ISO 9001 controlled quality record upon closure. A record tree structure allows cases/records to follow the configuration management of the product. The culmination of these features allows the user community to achieve product safety and reliability business management system over the full life cycle of a product. After two years of implementation and continuous improvement, a fundamental truth is proven. The process will only be sustainable and the database tool will only achieve long term success if the users feel their personal workflow facilitated by the system.


Title: Intelligent FMEA based on model FIORN

Source: ANNUAL RELIABILITY AND MAINTAINABILITY SYMPOSIUM, 2004 PROCEEDINGS

Author: Zhao, TD; Su, TJ; Xiao, H; Sun, LL

Year: 2004

Abstract: FMEA automation and intelligence are studied, which is an effective way to improving FMEA in product development. Firstly, we formed an intelligent FMEA framework that is an intelligent failure effect inference mechanism based on the target system model as well as using expert experience and considering failure modes input and output relationship between products in the system. This framework is comprised of three parts, failure mode analyzer, failure effect analyzer and FMEA report creator. Failure effect analysis based on system models. We form two system modeling methods, system hierarchical model based on expert knowledge and fault input/output relationship net(FIORN) model which describes the relationship among products belonging to the same level in the system. The latter based on failures' relationship and it could analyses correlated failures and common cause failures. Inference mechanism is presented based on these two models. Lastly, a prototype software -- iFMEA(intelligent FMEA) is developed. Intelligent FMEA technique is used in analysis of an aircraft's main gear system through which detail steps of intelligent FMEA method are described. System modeling method and inference mechanism are validated by this example.


Title: FMEA software program for managing preventive maintenance of medical equipment

Source: PROCEEDINGS OF THE IEEE 30TH ANNUAL NORTHEAST BIOENGINEERING CONFERENCE

Author: De Lemos, Z

Year: 2004

Abstract: As most health technology managers have noticed, there's no question that medical equipment used today for patient care has become more reliable. As technology has improved and continues to improve, the number and types of medical devices requiring preventive maintenance (PM), is being questioned amidst the pressure to reduce costs in the healthcare industry. The question now is how far should a Clinical Engineering (CE) department go to reduce the PM frequency of medical devices without compromising patient and user's safety? Answers can lie in the maintenance history of a particular piece of medical equipment or a group of medical devices. The focus of this project is to design and test a software tool to aid in the analysis and management of PM frequency using modified concepts of the Failure Mode and Effect Analysis (FMEA) methodology and statistical concepts to analyze PM history. A tool of such nature would aid management in revising their current PM frequency for certain medical devices and determine if it is necessary to alter the frequency in order to aid in cost reduction. This proposed program is specifically being designed for use in the Veterans Affair Medical Center in West Haven, Connecticut.


Title: Probabilistic safety assessment for a large industrial irradiator

Source: PROBABILISTI C SAFTEY ASSESSMENT AND MANAGEMENT, VOL 1- 6

Author: Lopez, R; Cuecuecha, ME; Mardian, J

Year: 2004

Abstract: This paper present the risk assessment performed for an irradiator of category IV panoramic. The probabilistic safety assessment (PSA) was developed by the Mexican Nuclear Regulatory Authority (CNSNS). The assessment was performed under a Research Contract signed with the International Atomic Energy Agency (IAEA), as part of the Coordinated Research Program (CRP) to Investigate Appropriate Methods and Procedures to Apply PSA Techniques of Large Radiation Sources. A thorough review of the incidents that have taken place in such facilities around the world has been performed to identify potential initiating events. The rise measures or end states associated with the irradiator facility have also been defined. A failure mode effect analysis (FMEA) has been carried out to define the possible events that give rise to disturbances in the plant and ha-e the potential to lead to consequences of concern. As a result, a complete list of initiating events has been set up. The analysis of the response of the plant due to the occurrence of disturbances that required a plant shutdown by means of event trees have also been performed. Fault trees have been developed for safety and operational systems. Coordinated efforts between CNSNS and MDS Nordion staff have been carried out to analyze specific function of safety equipment and understand their safety features for the development of accident sequences and fault trees. The operator response to an accident sequence was analyzed by means of the THERP methodology. In order to identify the potential benefits obtained with the application of a second HRA generation methodology, the ATHEANA methodology was applied at selected scenarios and their results are presented as sensitivity analysis. Finally, the quantification of accident sequences was completed using the SAPHIRE computer code.


Title: Socio-technical probabilistic risk assessment: Its application to patient safety

Source: PROBABILISTI C SAFTEY ASSESSMENT AND MANAGEMENT, VOL 1- 6

Author: Hale, M; Slonim, A; Allen, B; Marx, D; Kirkland, J

Year: 2004

Abstract: In 1999, the Institute of Medicine released its watershed report that put the public on notice of the 44,000 to 98,000 deaths in US hospitals arising from errors in hospitals each year. In partial response, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has required each accredited hospital to conduct at least one proactive risk assessment annually. JCAHO recommended Failure Modes and Effects Analysis (FMEA) as one tool for conducting this task. This article examines the limitations of FMEA and introduces a socio-technical version of probabilistic risk assessment that has been applied recently within the commercial aviation, space shuttle, and healthcare operations environments. Within healthcare, this adapted tool, known as Socio-Technical Probabilistic Risk Assessment (ST-PRA), provides one additional alternative for pro-actively identifying, prioritizing, and mitigating patient safety risk. While ST-PRA is a complex, high-end risk-modeling tool, it provides an opportunity to visualize system risk in a manner not possible through root cause analysis, failure modes and effects analysis, or other qualitative methods.


Title: FMEA as design monitor-, regulation- and management tool parallel to product design cycle for an optimised quality assurance

Source: PROBABILISTI C SAFTEY ASSESSMENT AND MANAGEMENT, VOL 1- 6

Author: Pickard, K; Muller, P; Bertsche, B

Year: 2004

Abstract: Contents of this paper is that after an exact comparison of qualitative quality management methods you come to the conclusion that FMEA (Failure Mode and Effects Analysis) according to VDA 4.2 can cover most of the other quality methods. This fact will be utilised to show the possibility to bring FMEA, with the help of software support, to a design monitor-, regulation- and management tool which can reasonably accompany the product design cycle of a new product.


Title: How do the management system's deficiencies affect on safety a case study of accomplishment of FMEA in a paper mill

Source: PROBABILISTI C SAFTEY ASSESSMENT AND MANAGEMENT, VOL 1- 6

Author: Adl, J; Pourparand, AM

Year: 2004

Abstract: The purpose of this study was to see how the existing management system can affect on safety activities like identification of hazards in the Digester by FMEA technique. Majority of managers did not believe that hazard identification can also be affected by some deficiencies of management system. Digester is the main apparatus in the paper mill, in which wood chips after Pre-Steaming Bin enter and by aid of chemicals convert to pulp. The under study Digester was a continues one-stage KAMYER system, producing KRAFT pulp in the capacity of similar to 200 M. tons per day. After listing all components of Digester (totally 28 components) and recognizing the failure modes of each component, for determination of failure rates we had to go through existing record keeping system. Three different sources, namely maintenance & process department and spare parts store records, were used. It was found that the records had two major inadequacies, One was their degree of accuracy; eg. In the process department records it was written that the Digester was shot down in such a time of a particular day and nothing about the reasons of this act and the duration of shot down. At the same time the records of two other sources did not show any thing related to this. The second major inadequacy was the long process of ordering spare parts from the store by maintenance department. There was a form for ordering parts, which required after filling by maintenance department few signatures and this was the reason for prolongation of the ordering process. When one of those bosses who should sign the form, was not accessible (this was the case on many occasions) the form would be left in his office for as long as he was not in. Therefore the maintenance department when in need of for instance a new filter for the In - Line Drainer to replace the old failed one, because of time consuming ordering process, they filled on the form the number of filters needed not one but eg. 5 filters in order to have 4 of them in the workshop and save them for the next time when filter fails. In the records of maintenance and process departments it was reflected as the filter of In - Line Drainer changed but in the spare parts store it was recorded 5 filters were delivered. Next time when the filter failed and had to be replaced the maintenance department did not fill the form and used one of those filters saved from previous time. As a result the records of store were again different than the other two sources of records. The maintenance department was also admitted that in many occasions some of those extra ordered filters which had been kept in workshop got lost or damaged during moving them from one location to another. Therefore it was not possible to find out how many filters have failed and replaced during the past 15 years. As result of this situation our FMEA work sheet was completed with some approximation and its validity were questioned. The highest failure rate was 69 per year for the In-Line Drainer and the lowest was 0.33 Per year for Blower and valve 128 A. From all 28 components only one ( valve 128 A) had a failure rate of 0.33 / y, which was in the range of failure rates for control valves given in the book of An introduction to machinery reliability assessment, by H.P. Bloch and F.K.Geitner, Van Nostrand Reinhold -1990. There was not any more failure rates to be verified in any of our references. It was concluded that for at least the sake of safety the management system should get rid of all those old fashioned bureaucratic procedures.


Title: Reliability-based classification criteria and their application procedures

Source: PROCEEDINGS OF THE FOURTEENTH (2004) INTERNATIONAL OFFSHORE AND POLAR ENGINEERING CONFERENCE, VOL 4

Author: Song, Y; Sasaki, S

Year: 2004

Abstract: A framework for establishing and applying reliability-based ship classification requirements complementary to current prescriptive rules has been proposed. After thoroughly examined the critical machinery failures that occurred on the ships registered with NIPPON KAIJI KYOKAI (ClassNK) over the past 20 years, the proposed procedure for reliability evaluation of propulsion system was found practicable and effective. The procedure employed a general Failure Mode and Effect Analysis (FMEA) method in combination with so-called cause effect analysis for determining important failure modes, and utilised Reliability Block Diagram (RBD)-based computer software to calculate the reliability and availability of a system quantitatively.


Title: Data modeling and management framework for voice of customer in financial industry

Source: SERVICE SYSTEMS AND SERVICE MANAGEMENT - PROCEEDINGS OF ICSSSM '04, VOLS 1 AND 2

Author: Pyon, CU; Hong, GH; Bae, SM; Park, SC

Year: 2004

Abstract: There are diverse channels to listen to VOC (Voice of Customer) in financial industry; such as internet homepage, ARS systems and call centers. For the integrated and practical analysis purpose, VOC data must have the same code structure. But, in real situation, VOC from various channels have a different code structure. It brings about inconsistency of analytical results. Although VOC are piled up in large quantities, the analysis results remain a description of past and present situation. This limited competency of analysis is basically caused by poor data model. Most existing VOC code structures have following problems; VOC code structures are too rigid to reflect market trends. Whenever new events occur, new code is added. As VOC code structures extend its size, VOC code structure becomes vague. Existing VOC code structure is not suitable for enterprise-wide analysis but transaction processing. In this paper, we suggest new VOC data model for VOC code structure as prerequisites for VOC management framework and propose the managerial implications. The suggested data model is flexible to reflect the characteristics of service industry. And we grasp the concept of TQM (Total Quality Management) such as FTA (Fault Tree Analysis) and FMEA (Failure Modes and Effect Analysis) and apply FOM (Family of Measurements) into the proposed model.


Title: From a single discipline risk management approach to an interdisciplinary one: Adaptation of FMEA to software needs

Source: ELEVENTH ANNUAL INTERNATIONAL WORKSHOP ON SOFTWARE TECHNOLOGY AND ENGINEERING PRACTICE, PROCEEDINGS

Author: Hartkopf, S

Year: 2004

Abstract: Risk management has been identified as a vitally important project management task. Hence, many risk management approaches have been developed. Unfortunately, most of them deal with the risks of a single discipline only, meaning disciplines in which either software or non-software products are developed. In contrast, nowadays many projects are highly interdisciplinary undertakings in the sense that newly developed conventional non-software products are enhanced by software. With the advent of software, many additional risks have emerged In this paper, the differences between software and non-software products are investigated. From these differences, consequences for interdisciplinary projects are derived. It is indicated how an interdisciplinary risk management approach can cope with the consequences. An answer is given to the question of how to achieve such an interdisciplinary approach. One possible solution is presented here as an adaptation of the Failure Modes and Effects Analysis, a single discipline approach, to the needs of software. This paper is an extension of a position paper presented at the STEP2003 Workshop of Interdisciplinary Software Engineering.


Title: Towards a unified approach to the representation of, and reasoning with, probabilistic risk information about software and its system interface

Source: 15TH INTERNATIONAL SYMPOSIUM ON SOFTWARE RELIABILITY ENGINEERING, PROCEEDINGS

Author: Feather, MS

Year: 2004

Abstract:


Title: A study on design process integration between marketing and R&D of notebook

Source: SHAPING BUSINESS STRATEGY IN A NETWORKED WORLD, VOLS 1 AND 2, PROCEEDINGS

Author: Tang, LL; Chin, YB; Lin, HS

Year: 2004

Abstract: This study focuses on building a framework which calculates the weights of FAHP (Fuzzy Analytical Hierarchical Process) method, then integrates the analysis tools such as FQFD (Fuzzy Quality Function Development) and FFMEA (Fuzzy Failure Mode and Effects Analysis) into the framework to construct a two-phase product specifications evaluation process. Therefore, this Study builds a framework and process of the new product specification evaluation which integrates the marketing attributes (the evaluation of the customers' demands), research attributes and development attributes and manufacture attributes (the evaluation of the failures and defects of the product specifications). It allows the product specifications which are produced by braining storm to be proceeded the evaluation before the prototype test phase and find the optimum product specification. It also can further the companies to optimize the organization resources. This research focuses on not only determining, but also transferring the market attributes to the product R&D specification in order to realize the relationship between the consumers' demands and the product specification. According to the methodologies represented, this study attempts to fill the gap in the literature by providing an integrative research framework and offers this framework to contribute the tasks and operations in the initial phase of the new product development and build the framework of multidimensional product specifications evaluation. Finally, an example of Notebook is used to illustrate the proposed approach.


Title: Integrating FMEA with TRIZ for eco-innovation

Source: ELECTRONICS GOES GREEN 2004 (PLUS): DRIVING FORCES FOR FUTURE ELECTRONICS, PROCEEDINGS

Author: Yen, SB; Chen, JL

Year: 2004

Abstract: This paper begins with an overview of current development of TRIZ-based eco-innovative design methods. Some suggestions for future research direction of TRIZ-based eco-innovation methods are proposed. Next, instead of as in traditional FMEA emphasizing potential failure risk, this paper proposes an approach that emphasizes environmental, safe and healthy aspects at normal operations. Taking the environment, safety and health into consideration, one can establish the synthetic indicator to evaluate the priority to remove the failures or reduce their risks. By integrating FMEA with the TRIZ inventive problem solving method, different kinds of innovative recommendations are systematically found out and then decisions are taken. This approach can be used in the early design stages as a supporting tool for designer to invent "novelty, usefulness, and no environmental burden" products.

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