Relevant bibliographies by topics / Maintenance errors

Academic literature on the topic 'Maintenance errors'

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Published: 6 September 2023

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Journal articles on the topic "Maintenance errors"

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NECULA, Florin, and Sorin-Eugen ZAHARIA. "CAPTURING HAZARDS AND ERADICATING HUMAN ERRORS IN AIRCRAFT MAINTENANCE." Review of the Air Force Academy 13, no. 3 (December 16, 2015): 155–60. http://dx.doi.org/10.19062/1842-9238.2015.13.3.27.

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Rankin, William L. "The Maintenance Error Decision Aid (MEDA) Process." Proceedings of the Human Factors and Ergonomics Society Annual Meeting 44, no. 22 (July 2000): 795–98. http://dx.doi.org/10.1177/154193120004402278.

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Maintenance and inspection errors have been the primary cause of six percent of aircraft accidents and have contributed to an additional nine percent of the accidents from 1982 through 1993. What can maintenance organizations do to reduce these types of errors? This paper discusses the development and evaluation of a maintenance error investigation process-the Maintenance Error Decision Aid (MEDA). MEDA was developed based on the following philosophy: maintenance technicians do not make errors on purpose; errors result from a series of related contributing factors, and; these factors are largely under management control and, therefore, can be improved to prevent future, similar errors. The MEDA process was field tested at nine maintenance organizations. After a one-day training course, airline personnel were able to carry out a successful MEDA investigation to determine and correct contributing factors to error. An average of 3.4 contributing factors was found per error. Since the end of the field test, Boeing has provided MEDA implementation support to over 120 aircraft maintenance organizations around the world. Feedback suggests that all organizations using MEDA have found cost-effective solutions to maintenance error.
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Wee, Nam-Sook. "Optimal Maintenance Schedules of Computer Software." Probability in the Engineering and Informational Sciences 4, no. 2 (April 1990): 243–55. http://dx.doi.org/10.1017/s026996480000156x.

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We present a decision procedure to determine the optimal maintenance intervals of a computer software throughout its operational phase. Our model accounts for the average cost per each maintenance activity and the damage cost per failure with the future cost discounted. Our decision policy is optimal in the sense that it minimizes the expected total cost. Our model assumes that the total number of errors in the software has a Poisson distribution with known mean λ and each error causes failures independently of other errors at a known constant failure rate. We study the structures of the optimal policy in terms of λ and present efficient numerical algorithms to compute the optimal maintenance time intervals, the optimal total number of maintenances, and the minimal total expected cost throughout the maintenance phase.
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Illankoon, Prasanna, and Phillip Tretten. "Judgemental errors in aviation maintenance." Cognition, Technology & Work 22, no. 4 (October 28, 2019): 769–86. http://dx.doi.org/10.1007/s10111-019-00609-9.

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Virovac, Darko, Anita Domitrović, and Ernest Bazijanac. "The Influence of Human Factor in Aircraft Maintenance." PROMET - Traffic&Transportation 29, no. 3 (June 27, 2017): 257–66. http://dx.doi.org/10.7307/ptt.v29i3.2068.

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Human factor is one of the safety barriers which is used in order to prevent accidents or incidents of aircraft. Therefore, the question is to which extent the error caused by human factor is included into the share of errors that are madeduring aircraft maintenance. In the EASA approved aircraft maintenance organisation, which includes in its working system the human factor as well, the tendency is to apply the approach by continuous monitoring and analysis of errors in aircraft maintenance. Such approach achieves advance prevention or reduction of the occurrence of harmful events, such as accidents, incidents, injuries and in a wider sense damages related to aircraft operation and maintenance. The research presented in this paper is a result of gathering and systematization of errors caused by human factors over the last five years in one organisation for aircraft maintenance certified according to the European standards. The study encompasses an analysis of 28 (twenty-eight) investigations of individual cases and provides insight into the main factors of errors. The results of analyses on the cause of occurrence of human error show similar results like the Boeing study which was carried out for the world fleet.
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Roy, Sophie, Céline Eiden, Irina Rasanjison, Véronique Pinzani, and Hélène Peyrière. "Medication errors involving opioid maintenance therapy." Therapies 75, no. 3 (May 2020): 295–97. http://dx.doi.org/10.1016/j.therap.2019.07.007.

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Hobbs, Alan, and Ann Williamson. "Associations between Errors and Contributing Factors in Aircraft Maintenance." Human Factors: The Journal of the Human Factors and Ergonomics Society 45, no. 2 (June 2003): 186–201. http://dx.doi.org/10.1518/hfes.45.2.186.27244.

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In recent years cognitive error models have provided insights into the unsafe acts that lead to many accidents in safety-critical environments. Most models of accident causation are based on the notion that human errors occur in the context of contributing factors. However, there is a lack of published information on possible links between specific errors and contributing factors. A total of 619 safety occurrences involving aircraft maintenance were reported using a self-completed questionnaire. Of these occurrences, 96% were related to the actions of maintenance personnel. The types of errors that were involved, and the contributing factors associated with those actions, were determined. Each type of error was associated with a particular set of contributing factors and with specific occurrence outcomes. Among the associations were links between memory lapses and fatigue and between rule violations and time pressure. Potential applications of this research include assisting with the design of accident prevention strategies, the estimation of human error probabilities, and the monitoring of organizational safety performance.
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Chervak, Steven G., and Colin G. Drury. "Effects of job instruction on maintenance task performance." Occupational Ergonomics 3, no. 2 (July 24, 2003): 121–31. http://dx.doi.org/10.3233/oer-2003-3204.

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Written documentation has been implemented in aviation maintenance errors so that documentation becomes an important safety issue. A restricted technical language for job instruction, Simplified English was tested to determine whether or not it reduced error rate in a maintenance task. Experienced and inexperienced participants performed on easy and a difficult maintenance task on a small internal combustion engine using three languages of job instruction: original, Simplified English and a hybrid. Task errors were reduced with Simplified English but increased with the hybrid version. While the easy task and the experienced participants made fewer errors, neither participant expertise nor task difficulty interacted with instruction language. Hence, Simplified English can be recommended, but hybrid instructions should be avoided.
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Islam, Rabiul, Rouzbeh Abbassi, Vikram Garaniya, and Faisal I. Khan. "Determination of Human Error Probabilities for the Maintenance Operations of Marine Engines." Journal of Ship Production and Design 32, no. 04 (November 1, 2016): 226–34. http://dx.doi.org/10.5957/jspd.2016.32.4.226.

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Human error is a crucial factor in the shipping industry and not to mention numerous human errors occur during the maintenance procedures of marine engines. Determination of human error probabilities (HEPs) is important to reduce the human errors and prevent the accidents. Nevertheless, determination of HEPs in the maintenance procedures of marine engines has not been given desired attention. The aim of this study is to determine the HEPs for the maintenance procedures of the marine engines to minimize the human errors and preclude accidents from the shipping industry. The Success Likelihood Index Method is used to determine the HEPs due to the unavailability of human error data for maintenance procedures of marine engines. The results showed that among the 43 considered activities in this study, inspection and overhauls piston/piston rings have the lowest HEP meaning it has a lower consequence for accidents. On the other hand, fuel and lubricating oil filters pressure difference checking and renews filter elements activity have the highest HEP indicating it has high chances for accidents.
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Nkosi, Mfundo, Kapil Gupta, and Madindwa Mashinini. "Causes and Impact of Human Error in Maintenance of Mechanical Systems." MATEC Web of Conferences 312 (2020): 05001. http://dx.doi.org/10.1051/matecconf/202031205001.

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The concept of minimizing human error in maintenance is progressively gaining attention in various industries. The incorporation of human factors when solving engineering problems, particularly in maintenance, can no longer be ignored where high standards of performance are expected. The journey of improving maintenance performance through the reduction of human error begins with the understanding of causes and impact of human error in maintenance. This paper evaluates previous scholarly writings on human errors, to specifically establish the causes and impact of human error in maintenance. This study relies predominantly on the existing literature on human error in maintenance derived from published and unpublished research. The primary findings emerging from the research exhibit a number of key factors that cause a human error in maintenance such as poor management and supervision, organizational culture, incompetence, poorly written procedures, poor communication, time pressure, plant and environmental conditions, poor work design and many more. The literature review also revealed that human errors have a negative impact on safety, reliability, productivity and efficiency of the equipment. It was further discovered that equipment failures leading to accidents, incidents, loss of life and economic losses are the major effects of human error. Human error in mechanical systems’ maintenance is a serious problem which needs adequate attention in order to develop corrective and preventive measures. This review paper serves as a basis for maintenance practitioners and interested parties to develop corrective and preventive measures for minimizing human error in the maintenance of mechanical systems.
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Dissertations / Theses on the topic "Maintenance errors"

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Abu, Hawwach Mohammed. "Human errors in industrial operations and maintenance." Thesis, Mälardalens högskola, Innovation och produktrealisering, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:mdh:diva-54794.

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Within maintenance activities and industrial operations, human is subjected to different kind of stresses and situation that could result in mistakes and accidents. The human errors in maintenance and manufacturing are an unexplored latter such that a little focusis invested in this area. The report aims to widen up the understanding of the human error in maintenance and manufacturing area. Aviation and marine operations are the most sectors that are subjected to human errors according tothe literature. There aredifferent types of human error that have effect on quality and overall effectivity. Human reliability models are one method to quantify human errors and usually used for the identification of human errors and HEP calculation. The most common reliability measurement methods are HEART, THERP and SLIM which are used depending on application and industry. As a part of efforts to define differences between those reliability models, literature including different industries is used and itis found that expert judgement influences the success and accuracy of such methods. There are many causes for human errors depending on the application but, communication and procedures followed are the most contributing factors. There is always a probability of existence of human errors as the mistake done by workers are inevitable. Industry 4.0 can help in decreasing human errors through the introduction of operator 4.0 as well as other approaches like training and upgrading organizational standards.
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Balasubramanian, Prashanth. "Root cause analysis-based approach for improving preventive/corrective maintenance of an automated prescription-filling system." Diss., Online access via UMI:, 2009.

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Thesis (M.S.)--State University of New York at Binghamton, Thomas J. Watson School of Engineering and Applied Science, Department of Systems Science and Industrial Engineering, 2009.
Includes bibliographical references.
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Bayramyan, Anna. "Making success out of failures : A quantitative research in Failure culture and Quality improvement." Thesis, Mittuniversitetet, Institutionen för kvalitets- och maskinteknik, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:miun:diva-40261.

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Companies can draw valuable lessons from their failures, and use them for their improvementwork. A positive failure culture is however a necessary precondition. High reliabilityorganisations (HRO) are known for their effective way of tackling and using failures aspotential for improvements. The aims of the study were to evaluate failure culture in an ISO9001 certified company, after HRO standards and thereby withdraw improvementpossibilities. The study was conducted through a deductive quantitative method using asurvey for data gathering. With approximately 30 percent response rate, and using statisticaltests, the failure culture of the company was evaluated. The results showed that the companyis not currently reaching a failure culture within HRO standards, but nevertheless has positivetendencies rather than negative. Lastly, improvement possibilities were discussed andsuggestions for further research were given.

2020-06-26

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Maier, Carl. "Elektronisk plattform för förebyggande underhåll på utrustning." Thesis, Högskolan i Skövde, Institutionen för informationsteknologi, 2020. http://urn.kb.se/resolve?urn=urn:nbn:se:his:diva-18657.

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Preventive maintenance is a process employed to reduce probability of failure or degradation of equipment. When such a process is performed by humans without a computerized solution, human errors are bound to take place. A computerized solution could reduce human errors by automatically performing tasks which are prone to error. A React web and a React Native application are created to evaluate which framework is most suitable for use in a preventive maintenance process based on three criteria. The criteria are round-trip request times, lines of code and delivery time based on build size. Results show that the React web application outperforms the React Native application in all three categories.
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Slack, Sean Edward. "Essays on categorical and universal welfare provision : design, optimal taxation and enforcement issues." Thesis, University of St Andrews, 2016. http://hdl.handle.net/10023/15659.

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Part I comprises three chapters (2-4) that analyse the optimal combination of a universal benefit (B≥0) and categorical benefit (C≥0) for an economy where individuals differ in both their ability to work and, if able to work, their productivity. C is ex-ante conditioned on applicants being unable to work, and ex-post conditioned on recipients not working. In Chapter 2 the benefit budget is fixed but the test awarding C makes Type I and Type II errors. Type I errors guarantee B > 0 at the optimum to ensure all unable individuals have positive consumption. The analysis with Type II errors depends on the enforcement of the ex-post condition. Under No Enforcement C > 0 at the optimum conditional on the awards test having some discriminatory power; whilst maximum welfare falls with both error propensities. Under Full Enforcement C > 0 at the optimum always; and whilst maximum welfare falls with the Type I error propensity it may increase with the Type II error propensity. Chapters 3 and 4 generalise the analysis to a linear-income tax framework. In Chapter 3 categorical status is perfectly observable. Optimal linear and piecewise-linear tax expressions are written more generally to capture cases where it is suboptimal to finance categorical transfers to eliminate inequality in the average social marginal value of income. Chapter 4 then derives the optimal linear income tax for the case with classification errors and Full Enforcement. Both equity and efficiency considerations capture the incentives an increase in the tax rate generates for able individuals to apply for C. Part II (Chapter 5) focuses on the decisions of individuals to work when receiving C, given a risk of being detected and fined proportional to C. Under CARA preferences the risk premium associated with the variance in benefit income is convex-increasing in C, thus giving C a role in enforcement.
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Ishihara, Yasuo. "Prediction of human error in rail car maintenance." Thesis, Massachusetts Institute of Technology, 1996. http://hdl.handle.net/1721.1/10629.

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McCracken, Michael E. "Maintenance Error Information System (MEIMS) upgrade and training evaluation." Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2000. http://handle.dtic.mil/100.2/ADA387421.

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Thesis (M.S. in Information Technology Management) Naval Postgraduate School, Dec. 2000.
Thesis advisors, Schmidt, John K. ; Brinkley, Douglas. "December 2000." Includes bibliographical references (p. 127-130). Also available in print.
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Fry, Ashley D. "Modeling and analysis of human error in Naval Aviation maintenance mishaps." Thesis, Monterey, Calif. : Springfield, Va. : Naval Postgraduate School ; Available from National Technical Information Service, 2000. http://handle.dtic.mil/100.2/ADA381266.

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Saward, Justin R. E. "Individual Latent Error Detection (I-LED) in UK naval aircraft maintenance." Thesis, University of Southampton, 2017. https://eprints.soton.ac.uk/417856/.

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System-induced human error is the most significant factor in aircraft accidents; for which errors are both inevitable and a frequent occurrence. Human error is a by-product of performance variability caused by system failures, for which undetected error becomes a latent error that can impact system safety and therefore contribute to a future undesired outcome. The phenomenon of Individual Latent Error Detection (I-LED) is proposed. ILED refers to the detection of workplace latent errors at some point post-task completion through the recollection of past activity by the individual who suffered the error. An extensive literature review shows the phenomenon to be a novel concept, indicating a clear gap in knowledge requiring research to explore the nature and extent of I-LED events. A multi-process theory is developed and combined with the systems perspective to provide a theoretical framework upon which to conduct real-world observations of ILED events in cohorts of naval air engineers. Collected data indicate time, location and other system cues trigger I-LED events, for which the deliberate review of past activity within a time window of two hours of the error occurring and whilst remaining in the same sociotechnical environment to that which the error occurred appears most effective. Several practicable interventions are designed and tested, from which the overall benefit of integrating the I-LED phenomenon as an additional safety control within an organisation’s safety system is assessed. This thesis contributes to knowledge on workplace safety by applying systems thinking to understand the nature and extent of I-LED and its benefit to safety resilience in naval aircraft maintenance through enhanced operator competence to detect latent errors. I-LED research arguably offers a step-change in safety thinking by offering a level of resilience within the workplace that has not previously been accounted for in organisational safety strategies.
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Schmorrow, Dylan D. "A human error analysis and model of naval aviation maintenance related mishaps." Thesis, Monterey, California. Naval Postgraduate School, 1998. http://hdl.handle.net/10945/44430.

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Approved for public release; distribution is unlimited
Naval Aviation is in the midst of a major transformation as it attempts to come to terms with the demands of maintaining operational readiness in the face of diminishing budgets and reduced manning. Diminishing operating and procurement budgets mean that Naval Aviation is for the most part "making do" with existing aircraft. Over the past decade, one in four Naval Aviation mishaps were partially attributable to maintenance error. The present operating environment underscores the need to address maintenance error and its causes. The current study accomplishes three things. First, it evaluates 470 Naval Aviation mishaps with distinct maintenance error correlates. Second, it categorizes those errors using a taxonomy based upon current organizational and psychological theories of human error. Third, it mathematically models the consequences of these errors and uses the models to (a) predict the .frequency with which maintenance-based mishaps will occur in the future and (b) approximate the potential cost savings from the reduction of each error type.
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Books on the topic "Maintenance errors"

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Hang kong wei xiu cha cuo guan li li lun yu shi jian. Beijing: Guo fang gong ye chu ban she, 2013.

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Gueson, Emerita T. Survival guide for HMO patients. Bensalem, PA: ThereseVision Publications, 1997.

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Gueson, Emerita T. Do HMO's cut costs-- and lives?: Medical malpractice crisis in PA. [Bloomington, Ind: AuthorHouse, 2006.

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James, Albert L. Why are contractors always late? Salt Lake City, UT: American Book Business Press, 2007.

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Human reliability, error, and human factors in engineering maintenance: With reference to aviation and power generation. Boca Raton: Taylor & Francis, 2009.

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S, Dhillon B. Human reliability, error, and human factors in power generation. Cham: Springer, 2014.

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McCracken, Michael E. Maintenance Error Information System (MEIMS) upgrade and training evaluation. Monterey, Calif: Naval Postgraduate School, 2000.

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Office, General Accounting. Social security: Pension data useful for detecting supplemental security payment errors : report to the Secretary of Health and Human Services. Washington, D.C: The Office, 1986.

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Fry, Ashley D. Modeling and analysis of human error in Naval Aviation maintenance mishaps. Monterey, Calif: Naval Postgraduate School, 2000.

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Wood, Brian P. Information management system development for the characterization and analysis of human error in Naval Aviation maintenance related mishaps. Monterey, Calif: Naval Postgraduate School, 2000.

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Book chapters on the topic "Maintenance errors"

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Wakimizu, Toshiyuki, Atsuo Murata, Toshihisa Doi, Yutaka Yoshida, and Keisuke Fukuda. "Correlations Between Inspections, Maintenance Errors, and Accidents." In Lecture Notes in Networks and Systems, 477–82. Cham: Springer International Publishing, 2021. http://dx.doi.org/10.1007/978-3-030-80713-9_61.

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Vega, Manuel A., Zhen Hu, and Michael D. Todd. "Effect of Inspection Errors in Optimal Maintenance Decisions for Deteriorating Quoin Blocks in Miter Gates." In Model Validation and Uncertainty Quantification, Volume 3, 1–4. Cham: Springer International Publishing, 2022. http://dx.doi.org/10.1007/978-3-030-77348-9_1.

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Thulasy, T. Nanthakumaran, Puteri N. E. Nohuddin, Norlizawati Abd Rahim, and Astuty Amrin. "Literature Survey on Aircraft Maintenance Issues with Human Errors and Skill Set Mismatch Using Document Mining Technique." In Advances in Visual Informatics, 53–64. Cham: Springer International Publishing, 2021. http://dx.doi.org/10.1007/978-3-030-90235-3_5.

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Yiannakides, Demetris, and Charalampos Sergiou. "Human Error." In Human Factors in Aircraft Maintenance, 85–102. Boca Raton : CRC Press, 2019.: CRC Press, 2019. http://dx.doi.org/10.1201/9780429280887-7.

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Konersmann, Marco, and Michael Goedicke. "Same but Different: Consistently Developing and Evolving Software Architecture Models and Their Implementation." In Ernst Denert Award for Software Engineering 2019, 87–112. Cham: Springer International Publishing, 2020. http://dx.doi.org/10.1007/978-3-030-58617-1_6.

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AbstractAs software architecture is a main driver for the software quality, source code is often accompanied by software architecture specifications. When the implementation is changed, the architecture specification is often not updated along with the code, which introduces inconsistencies between these artifacts. Such inconsistencies imply a risk of misunderstandings and errors during the development, maintenance, and evolution, causing serious degradation over the lifetime of the system. In this chapter we present the Explicitly Integrated Architecture approach and its tool Codeling, which remove the necessity for a separate representation of software architecture by integrating software architecture information with the program code. By using our approach, the specification can be extracted from the source code and changes in the specification can be propagated to the code. The integration of architecture information with the code leaves no room for inconsistencies between the artifacts and creates links between artifacts. We evaluate the approach and tool in a use case with real software in development and with a benchmark software, accompanied by a performance evaluation.
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Dhillon, B. S. "Human Reliability and Error in Maintenance." In Handbook of Maintenance Management and Engineering, 695–710. London: Springer London, 2009. http://dx.doi.org/10.1007/978-1-84882-472-0_25.

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Dhillon, B. S. "Human Error in Power Plant Maintenance." In Springer Series in Reliability Engineering, 135–49. Cham: Springer International Publishing, 2014. http://dx.doi.org/10.1007/978-3-319-04019-6_10.

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Nicholas, Clive. "Human Error in Maintenance – A Design Perspective." In Handbook of Maintenance Management and Engineering, 711–35. London: Springer London, 2009. http://dx.doi.org/10.1007/978-1-84882-472-0_26.

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Sakajo, Satoko, Wei Wu, and Tadashi Ohi. "Human Error Analysis Support System for Maintenance Works." In Probabilistic Safety Assessment and Management, 20–25. London: Springer London, 2004. http://dx.doi.org/10.1007/978-0-85729-410-4_4.

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Kimura, Mitsutaka. "Reliability Analysis of Congestion Control Scheme with Code Error Correction Methods." In Reliability and Maintenance Modeling with Optimization, 119–36. Boca Raton: CRC Press, 2023. http://dx.doi.org/10.1201/9781003095231-7.

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Conference papers on the topic "Maintenance errors"

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Saull, John W. "Reducing Human Errors in Aircraft Maintenance." In Advances In Aviation Safety Conference & Exposition. 400 Commonwealth Drive, Warrendale, PA, United States: SAE International, 2001. http://dx.doi.org/10.4271/2001-01-2665.

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Vetter, Arthur. "Detecting Operator Errors in Cloud Maintenance Operations." In 2016 IEEE International Conference on Cloud Computing Technology and Science (CloudCom). IEEE, 2016. http://dx.doi.org/10.1109/cloudcom.2016.0110.

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Douce, C. R., and P. J. Layzell. "Evolution and errors: an empirical example." In Proceedings IEEE International Conference on Software Maintenance - 1999 (ICSM'99). 'Software Maintenance for Business Change' (Cat. No.99CB36360). IEEE, 1999. http://dx.doi.org/10.1109/icsm.1999.792647.

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Russell, S. G. "The factors influencing human errors in military aircraft maintenance." In International Conference on People in Control (Human Interfaces in Control Rooms, Cockpits and Command Centres). IEE, 1999. http://dx.doi.org/10.1049/cp:19990198.

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Bhatia, Arti, N. S. Mangat, and Tom Morrison. "Estimation of Measurement Errors." In 1998 2nd International Pipeline Conference. American Society of Mechanical Engineers, 1998. http://dx.doi.org/10.1115/ipc1998-2038.

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A check of the measurement ability of the tools used to assess the corrosion on a pipeline is an important aspect of a maintenance program. In this paper a statistical method of determining the errors of measurement instruments is examined.
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Rupakheti, Chandan R., and Daqing Hou. "Finding errors from reverse-engineered equality models using a constraint solver." In 2012 IEEE International Conference on Software Maintenance (ICSM). IEEE, 2012. http://dx.doi.org/10.1109/icsm.2012.6405256.

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Patankar, Manoj S., and James C. Taylor. "Analyses of Organizational and Individual Factors Leading to Maintenance Errors." In Advances In Aviation Safety Conference & Exposition. 400 Commonwealth Drive, Warrendale, PA, United States: SAE International, 2001. http://dx.doi.org/10.4271/2001-01-3005.

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Maillart, L. M., and S. M. Pollock. "The effect of failure-distribution specification-errors on maintenance costs." In Annual Reliability and Maintainability. Symposium. 1999 Proceedings (Cat. No.99CH36283). IEEE, 1999. http://dx.doi.org/10.1109/rams.1999.744099.

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Balkey, Joseph P. "Common Components of Human Error in Design, Maintenance, or Operations." In ASME 2003 International Mechanical Engineering Congress and Exposition. ASMEDC, 2003. http://dx.doi.org/10.1115/imece2003-42761.

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Often, public reports of accidents only identify the last, obvious failure or immediate cause of the accident. If human error is the immediate cause or final failure, further assessment of accident contributors may stop, and an enhanced training program is often determined to be the primary solution for preventing further accidents of this type. However, in many cases, the accident is the final result of many inputs, decisions, actions and inactions. To demonstrate this characteristic of accidents, the 20 stories in a publication titled “Set Phasers on Stun” have been categorized into action errors and planning errors that involve designers, mechanics, or operators. For each story, the hazard and the number of simultaneous failures are listed. Then two of the 20 stories are assessed in detail; one story involves an action error and the other one involves a planning error. In each of these two stories, the system is first described as it should operate and then its risk is quantitatively assessed to identify findings, lessons learned, recommendations, analogies to the other 18 stories, and applications. This paper has three immediate goals. One, to recognize the difference between an action error and a planning error. Two, to recognize that most accidents involve 2 to 4 simultaneous failures. Three, to appreciate that quantifying the failure frequency serves two benefits. Because it is usually difficult to find out exactly what happened after an accident, the calculated frequency can help confirm what actually happened. When various alternatives are recommended, it can also help to select the most economic ones. This paper has two long term goals. One, consider assessing the failure rates of near misses. By reducing near misses, larger accidents will be reduced. Two, consider assessing the failure rates of personal near misses because you know what actually happened.
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10

Bernard, Fabien, Raphael Paquin, and Kévin Dos-Santos. "Human Errors in Helicopter Maintenance: overview of recommendations for improving safety." In 14th International Conference on Applied Human Factors and Ergonomics (AHFE 2023). AHFE International, 2023. http://dx.doi.org/10.54941/ahfe1003617.

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The maintenance is defined as the second cause of aviation incidents or accidents. Indeed, 12% of all aviation accidents were due to human factors/ergonomics (HFE) issues during maintenance activity (Hobbs, 2000). However, regarding the aviation history, Human performance has been studied from the very beginning in the aviation field, especially regarding fixed wing accidents (Maurino et al., 1993; Wiener & Nagel, 1988). Initially, the reliability of machines was the primary concern, and many attempts were made to improve the technology of the devices (Maurino et al., 1993; Wiener & Nagel, 1988). During the following decades, HFE raised as a discipline to design the flight deck and to investigate the interaction between human (pilot) and machine, particularly, during the training phase of the pilot in a simulator (Wiener & Nagel, 1988; Horeman et al., 2015). Safety and comfort in the cockpit and the passenger cabin were also improved by considering HFE principles during the subsequent decades (Spenser, 2008). The consideration of Human Factors in maintenance is more recent. Integrating HFE in maintainability increases the quality of maintenance activities and reduces the rate of mistakes/errors (Gruber et al., 2015). The design engineers in the maintainability department interact and collaborate with other engineering departments (e.g., aerodynamic, hydraulic and electric integration, and architecture) and support disciplines including aircraft maintenance manual to consider maintenance & HF criteria during design phases. This interaction could raise HFE culture between them could effectively affect the future maintenance activity. However, aviation accidents are not the only problem that demonstrates the need to improve HFE for maintenance activities. The health and safety of maintenance operators is also a key contributor to maintenance errors (Hobbs, 2000). Various studies have already highlighted the fact that maintenance activities can cause health problems (musculoskeletal disorders, stress, and high mental workload) and workplace accidents (AFIM, 2004; European Agency for Safety and Health at Work, 2010). In a survey of 2,500 maintenance operators from various industries (automotive, train, and aeronautics), AFIM showed that 62% of respondents considered their occupation to be dangerous. Another study performed in Europe showed that 15%–20% of accidents at work occurred in the field of maintenance, suggesting that maintenance tasks are the most dangerous activities in an industry (European Agency for Safety and Health at Work, 2010).In order to reduce the risk of error, and also improve the work condition of maintenance operator, one of the solution is to better understand the current feedback of customer’s daily activity. Airbus Helicopters has launched a huge campaign of preventive Human Factors analysis. In this frame, the most sensitive maintenance tasks on existing helicopters have been studied to impact the design, procedure, maintenance tools and training. These maintenance tasks mainly concern sensitive mechanical system (Main Rotors, Main Rotor Drives, Tail Rotor, Tail Rotor Drives and Rotor Flight Control) regrouping lots of critical parts. In this article, we will first present a brief background of Human Factors in aviation maintainability. Then we will describe the methodologies and tools used to assess Human Factors dimensions during the observation of sensitive maintenance tasks. Additionally, we will introduce the main results and outcomes of all this analysis, all tasks and helicopters combined. We will provide some safety recommendations and improvement in the design & maintenance procedure for future development, mainly by highlighting six categories (Work at Height, Foreign Object Damages, Incorrect assembly, Number of Operators requested to perform the maintenance task, Damage prevention, Damage identification).
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Reports on the topic "Maintenance errors"

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Smalley, Mauney, and Ash. L51770 Compressor Station Maintenance Cost Analysis. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), May 1997. http://dx.doi.org/10.55274/r0010164.

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A comprehensive study of compressor maintenance data including capital and expense to identify the drivers for optimizing maintenance cost expenditures. Anonymous company comparisons which allow individual companies to compare their maintenance expenses to others in the industry, using various methods of normalization. Correlations by linear regression to characterize relationships between expense and various measures of size (deliveries, installed horsepower, horsepower hours, miles/KM of pipeline, capital value, number of units). This report provides information on the maintenance of compressors for gas transmission. It starts with a survey designed to characterize the pipeline industry's practice in managing maintenance and recording maintenance data; to gather hard data on maintenance expense and its drivers; and identifies opportunities to optimize maintenance expenditures. The report describes the survey and the goal of each question, then presents the results, which include data on consistency of FERC Form 2 filing practices, availability of hard data, distribution of expenses, budgeting and decision making practices. The assembled responses also include a list of practices which individual companies perceive as unique or especially beneficial; a list of perceived opportunities for controlling or optimizing maintenance and perceived needs for research, products, data, and tools to support future maintenance optimization. Results include regression coefficients and standard errors (which help characterize the relationship), and the inferred slope with its own standard error (which helps quantify the dependence of the expense on these various independent variables). These correlations have included available data for combined O and M and fuel use as expenses. This study conducted over numerous years has assembled a number of valuable databases, and the report describes these and the use which the project has made of them. The report also provides various analyses and presentation of maintenance information based on detailed analysis of these data bases. Analysis of company totals, maintenance for individual compressor stations, for individual units, or for different models within the systems of individual companies. A final analysis and supporting documentation is provided that applies data from FERC filings for combined O and M, fuel use and fuel or power cost by station.
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George and Hawley. PR-015-11702-R01 Evaluation of Enhanced Diagnostics for Orifice Meters. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), January 2013. http://dx.doi.org/10.55274/r0010795.

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A large installed base of orifice meters, many installed where newer technology meters are impractical, accounts for a significant fraction of the measured volume of natural gas in the United States. Ultrasonic meters are newer technology meters that provide integrated diagnostics to monitor the meters health and identify flow problems such as distorted velocity profiles and other operational issues. The need exists for similar diagnostics for orifice meters to identify operational causes of measurement errors (and possibly measure their magnitudes), allow users to perform orifice meter maintenance as needed, reduce maintenance costs, and reduce the fiscal impact of significant measurement errors. Research was conducted to identify and recommend candidate technologies for development into practical, cost-effective orifice meter diagnostic tools..
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George and Hawley. PR-015-10602-R01 Effects of Liquid Contamination on Ultrasonic Flow Meter Performance. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), August 2012. http://dx.doi.org/10.55274/r0010787.

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A known cause of error in in-line ultrasonic meters is the presence of liquid contamination on transducer faces. These liquids can come from unconventional or poor-quality gas supplies, but compressor oil or glycol can also enter the natural gas stream due to problems with upstream equipment. It has been suspected that liquid contamination produces a fundamental measurement error in ultrasonic pulse transit time, which leads to biases in the measured sound speed of the gas and, ultimately, flow measurement errors. Operators presently observe such differences in measured sound speeds, but often do not understand that they may be linked to the presence of liquids. Having such an understanding could lead to solutions to manage the problem, such as diagnostics to identify the cause of the liquid contamination and prompt maintenance on the equipment producing the liquids. Such diagnostics could reduce the resulting measurement errors and related lost-and-unaccounted-for (LAUF) gas amounts. This report documents a research project to characterize ultrasonic meter response to liquid contaminants produced by pipeline operations, particularly compressor oil and glycol. Tests were performed using multiple brands of ultrasonic meters and multiple types of transducers, with flow data and diagnostics collected from each meter. The data were analyzed to answer three questions: (1) how the diagnostic ability of the meter depends upon the meter and transducer designs, (2) whether ultrasonic meter diagnostics can identify liquid contaminant types, and (3) how various liquid contaminants affect measurement accuracy.
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Leis, Brian, Xian-Kui Zhu, and Tom McGaughy. PR-185-143600-R01 Assessment of Corrosion Model Error for Metal-loss Defects in Pipelines. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), July 2017. http://dx.doi.org/10.55274/r0011031.

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This project assessed the modeling error of current Level 1 corrosion criteria of ASME B31G and Modified B31G by quantifying the role of the shape factor (SF) and the bulging factor (BF) as causes for large scatter of failure predictions. The goal was to minimize the error and to reduce the conservatism in those corrosion assessment models and potentially reduce unwarranted maintenance efforts without increasing operator risk. Extensive elastic-plastic finite element analyses (FEA) were performed on corroded pipes in three-dimensional conditions for a wide range of corrosion defect shapes and sizes, pipe geometries, grades, and material properties. The FEA results were trended as the basis to reformulate a new corrosion criterion.
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Popov, Oleksandr O., Anna V. Iatsyshyn, Andrii V. Iatsyshyn, Valeriia O. Kovach, Volodymyr O. Artemchuk, Viktor O. Gurieiev, Yulii G. Kutsan, et al. Immersive technology for training and professional development of nuclear power plants personnel. CEUR Workshop Proceedings, July 2021. http://dx.doi.org/10.31812/123456789/4631.

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Training and professional development of nuclear power plant personnel are essential components of the atomic energy industry’s successful performance. The rapid growth of virtual reality (VR) and augmented reality (AR) technologies allowed to expand their scope and caused the need for various studies and experiments in terms of their application and effectiveness. Therefore, this publication studies the peculiarities of the application of VR and AR technologies for the training and professional development of personnel of nuclear power plants. The research and experiments on various aspects of VR and AR applications for specialists’ training in multiple fields have recently started. The analysis of international experience regarding the technologies application has shown that powerful companies and large companies have long used VR and AR in the industries they function. The paper analyzes the examples and trends of the application of VR technologies for nuclear power plants. It is determined that VR and AR’s economic efficiency for atomic power plants is achieved by eliminating design errors before starting the construction phase; reducing the cost and time expenditures for staff travel and staff training; increasing industrial safety, and increasing management efficiency. VR and AR technologies for nuclear power plants are successfully used in the following areas: modeling various atomic energy processes; construction of nuclear power plants; staff training and development; operation, repair, and maintenance of nuclear power plant equipment; presentation of activities and equipment. Peculiarities of application of VR and AR technologies for training of future specialists and advanced training of nuclear power plant personnel are analyzed. Staff training and professional development using VR and AR technologies take place in close to real-world conditions that are safe for participants and equipment. Applying VR and AR at nuclear power plants can increase efficiency: to work out the order of actions in the emergency mode; to optimize the temporary cost of urgent repairs; to test of dismantling/installation of elements of the equipment; to identify weaknesses in the work of individual pieces of equipment and the working complex as a whole. The trends in the application of VR and AR technologies for the popularization of professions in nuclear energy among children and youth are outlined. Due to VR and AR technologies, the issues of “nuclear energy safety” have gained new importance both for the personnel of nuclear power plants and for the training of future specialists in the energy sector. Using VR and AR to acquaint children and young people with atomic energy in a playful way, it becomes possible to inform about the peculiarities of the nuclear industry’s functioning and increase industry professions’ prestige.
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Zanker. PR-343-06604-R02 Smart USM Diagnostics - Phase 2. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), August 2009. http://dx.doi.org/10.55274/r0010758.

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It has long been known that all ultrasonic flow meters, especially those that exploit multiple paths to achieve higher accuracies, are capable of extensive self-diagnosis. However, each manufacturer of the technology has tended to develop diagnostic tools peculiar to his particular device. This has led to a confusing mix of offerings that are not transportable between meters, and whose interpretations are not always consistent. This report addresses: � Verification of the Phase 1 models against available field data; � Implementation of field-tested methods offered by PRCI users; � Trending the diagnostics with time to detect changes; � Establishing the significance of the changes (magnitude of error); � Deciding if the changes require intervention (maintenance, re-calibration); � Tuning of the Phase 1 models based on this experience; � Verification of the models using experimental testing.
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Zhu, Xian-Kui, Tom McGaughy, and Brian Leis. PR-185-163609-R01 Model Error Assessment for Pipeline Metal-loss Defects Phase II. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), July 2018. http://dx.doi.org/10.55274/r0011506.

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This project included seven, full-scale burst tests conducted on a single grade and size of pipe to evaluate a metal-loss defect assessment model developed under EWI Project No. 54922CSP, "Assessment of Corrosion Model Error for Metal Loss Defects in Pipelines" (PRCI Project EC-2-6). The goal of the modeling and full-scale test efforts was to minimize error and reduce the conservatism of Level-1 corrosion assessment models, with the eventual benefit of potentially reducing unwarranted maintenance efforts without increasing operator risk. Seven tests were performed on a recent vintage of API 5L X70M (L485M) grade pipe having an outside diameter of 24 in. (610 mm) and nominal wall thickness of 0.50 in. (12.7 mm). The seven test pipes contained machined flat-bottomed defects for which the Shape Factor is 1, to focus on the role of the planar defect size and its depth and avoid the complexities of river-bottom shaped defects that are beyond the current scope. Defect lengths ranged between 3 and le; L/(Dt)0.5 and le; 10, at bounding values of width taken at arc angles of 20 and 60 degrees, and depth at d/t of 30% and 80%. The simulated corrosion was centered in pups approximately 12 ft (~3.7 m) in length, which is sufficient to prevent any interaction between the end caps with the defects. The pipes were then end-capped and pressurized with water to failure. The actual failure pressures were evaluated relative to predictions based on the model developed in EC-2-7 coupled with the reference stress developed in PRCI Project EC-2-6.
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Wilcox. PR-015-09200-R01A Compressor and Pump Station Incidents and Technology Gaps. Chantilly, Virginia: Pipeline Research Council International, Inc. (PRCI), October 2009. http://dx.doi.org/10.55274/r0010956.

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In 2008, Pipeline Research Council International (PRCI) took the initiative to identify the main causes of reportable incidents in compressor and pump stations. Data was gathered from several sources including the United States� Department of Transportation Pipeline and Hazardous Materials Safety Administration, Canada�s National Energy Board, and PRCI member companies. More than 1600 incidents were reviewed over an 18 year period (1990 to 2008). The incidents were evaluated based on their frequency of occurrence and the consequences of the incidents (injury, ignition, environmental impact, etc�). In pump stations, pump seals, valves out of sequence due to operator error, and gasket and bolting were identified as the highest impact incidents types. In compressor stations, the three highest impact incident types were found to be pipe components, natural forces (hurricanes and lightning strikes), and gaskets and bolting. During the 2008 project, research roadmaps were developed based on the results of the incident data review. In the process of defining the research projects, a brief review into the available technology for the incidents types was conducted. It was quickly found that a more detailed state-of-the-art review was needed to accurately identify the research required for several of the incident areas. Therefore, a state-of-the-art review of the three highest impact incidents in pump and compressor stations was proposed. The work documented in this paper is the state-of-the-art review of these incidents. In the PRCI CPS 9-1 (2008) project, it was found that more information was needed on several of the incidents in order to fully define the root cause. Therefore, the first task of the PRCI CPS 9-1 (2009) effort was to attempt to gather more information on the top three impact incident types. Thirty-two pipeline companies were contacted and additional information was provided for approximately 25% of the incidents. From the review of this additional and past data, several focus areas were identified for the state-of-the-art reviews. The state-of-the-art studies included a survey of the current technology, identification of common failure mechanisms, and review of strategies to reduce incident occurrences. These studies are reviewed in detail in the appendices of this document. From the state-of-the-art studies and the incident review, technology gaps were identified. Technology gaps are areas where new innovative technologies or applications are required to address current inspection/maintenance strategies for a particular piece of equipment or task. Technology gaps were only identified for pump seals. These gaps included the inability for pump seals to survive process upset conditions, inability to correctly identify and model expected loads and operating conditions for pump seal selection, and lack of installed seal inspection or life prediction methods except through leakage detection. All other incident types (valves out of sequence due to operator error, gaskets and bolting, pipe components, and natural forces) have adequate technology to address the incident occurrences. In the majority of the incidents, even though the technologies exist, it may not be used or applied correctly. Several recommendations were made for future work. These included work that a company may consider conducting internally to reduce the occurrence of incidents and future research. The recommendations for future work for operators and research for industry are summarized in a list below. Research items included on the research roadmaps are indicated with an asterisk.
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