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Root Cause (root + cause)
Terms modified by Root Cause Selected AbstractsApplication of Multivariate Data Analysis for Identification and Successful Resolution of a Root Cause for a Bioprocessing ApplicationBIOTECHNOLOGY PROGRESS, Issue 3 2008Alime Ozlem Kirdar Multivariate Data Analysis (MVDA) can be used for supporting key activities required for successful bioprocessing. These activities include process characterization, process scale-up, process monitoring, fault diagnosis and root cause analysis. This paper examines an application of MVDA towards root cause analysis for identifying scale-up differences and parameter interactions that adversely impact cell culture process performance. Multivariate data analysis and modeling were performed using data from small-scale (2 L), pilot-scale (2,000 L) and commercial-scale (15,000 L) batches. The input parameters examined included bioreactor pCO2, glucose, lactate, ammonium, raw materials and seed inocula. The output parameters included product attributes, product titer, viable cell density, cell viability and osmolality. Time course performance variables (daily, initial, peak and end point) were also evaluated. Application of MVDA as a diagnostic tool was successful in identifying the root cause and designing experimental conditions to demonstrate and correct it. Process parameters and their interactions that adversely impact cell culture performance and product attributes were successfully identified. MVDA was successfully used as an effective tool for collating process knowledge and increasing process understanding. [source] Management and Recovery Options for Ural River Beluga SturgeonCONSERVATION BIOLOGY, Issue 3 2010PHAEDRA DOUKAKIS caviar; CITES; criadero; Mar Caspio; puntos de referencia; sobrepesca Abstract:,Management of declining fisheries of anadromous species sometimes relies heavily on supplementation of populations with captive breeding, despite evidence that captive breeding can have negative consequences and may not address the root cause of decline. The beluga sturgeon (Huso huso), a species threatened by the market for black caviar and reductions in habitat quality, is managed through harvest control and hatchery supplementation, with an emphasis on the latter. We used yield per recruit and elasticity analyses to evaluate the population status and current levels of fishing and to identify the life-history stages that are the best targets for conservation of beluga of the Ural River. Harvest rates in recent years were four to five times higher than rates that would sustain population abundance. Sustainable rates of fishing mortality are similar to those for other long-lived marine species such as sharks and mammals. Yield per recruit, which is maximized if fish are first harvested at age 31 years, would be greatly enhanced by raising minimum size limits or reducing illegal take of subadults. Improving the survival of subadult and adult females would increase population productivity by 10 times that achieved by improving fecundity and survival from egg to age 1 year (i.e., hatchery supplementation). These results suggest that reducing mortality of subadults and adult wild fish is a more effective conservation strategy than hatchery supplementation. Because genetics is not factored into hatchery management practices, supplementation may even reduce the viability of the beluga sturgeon. Resumen:,El manejo de pesquerías de peces anádromos en declinación a veces depende estrechamente de la suplementación de poblaciones mediante la reproducción en cautiverio, no obstante la evidencia de que la reproducción en cautiverio puede tener consecuencias negativas y no abordar la causa principal de la declinación. El esturión beluga (Huso huso), una especie amenazada por el mercado de caviar negro y por reducciones en la calidad del hábitat, es manejado mediante el control de la cosecha y suplementación de poblaciones, con énfasis en esta. Utilizamos análisis de producción por recluta y de elasticidad para evaluar el estatus de la población y los niveles de pesca actuales y para identificar las etapas de la historia de vida que son los mejores blancos para la conservación del beluga en el Río Ural. Las tasas de cosecha en años recientes fueron cuatro a cinco veces mayores que las tasas que sustentarían la abundancia de la población. Las tasas sustentables de mortalidad por pesca son similares a las de otras especies marinas longevas como tiburones y mamíferos. La producción por recluta, que es maximizada si los peces son cosechados a la edad de 31 años, podría incrementar significativamente elevando los límites de talla mínima o reduciendo la captura ilegal de subadultos. La mejora de la supervivencia de hembras subadultas y adultas incrementaría la productividad de la población 10 veces más que la mejora obtenida incrementando la fecundidad y supervivencia de huevo a 1 año de edad (i. e., suplementación de poblaciones mediante reproducción en cautiverio). Estos resultados sugieren que la reducción de la mortalidad de peces silvestres subadultos y adultos es una mejor estrategia de conservación que la suplementación. Debido a que la genética no es considerada en las prácticas de manejo en los criaderos, la suplementación incluso puede reducir la viabilidad del esturión beluga. [source] Economic Growth and Biodiversity Loss in an Age of Tradable PermitsCONSERVATION BIOLOGY, Issue 4 2006JON ROSALES comercio de emisiones; límite y comercio; proceso ciencia-política; Protocolo de Kyoto Abstract:,Tradable permits are increasingly becoming part of environmental policy and conservation programs. The efficacy of tradable permit schemes in addressing the root cause of environmental decline,economic growth,will not be achieved unless the schemes cap economic activity based on ecological thresholds. Lessons can be learned from the largest tradable permit scheme to date, emissions trading now being implemented with the Kyoto Protocol. The Kyoto Protocol caps neither greenhouse gas emissions at a level that will achieve climate stability nor economic growth. If patterned after the Kyoto Protocol, cap-and-trade schemes for conservation will not ameliorate biodiversity loss either because they will not address economic growth. In response to these failures to cap economic growth, professional organizations concerned about biodiversity conservation should release position statements on economic growth and ecological thresholds. The statements can then be used by policy makers to infuse these positions into the local, national, and international environmental science-policy process when these schemes are being developed. Infusing language into the science-policy process that calls for capping economic activity based on ecological thresholds represents sound conservation science. Most importantly, position statements have a greater potential to ameliorate biodiversity loss if they are created and released than if this information remains within professional organizations because there is the potential for these ideas to be enacted into law and policy. Resumen:,Cada vez más, los permisos comerciables son parte de la política ambiental y de los programas de conservación. La eficacia de los esquemas de permisos comerciables para atender la causa principal de la declinación ambiental,crecimiento económico,será baja a menos que los esquemas limiten la actividad económica con base en umbrales ecológicos. Se pueden aprender lecciones del mayor esquema de permisos comerciables a la fecha, la comercialización de emisiones implementada con el Protocolo de Kyoto. El Protocolo de Kyoto no limita a las emisiones de gases a un nivel que logre la estabilidad climática ni al crecimiento económico. Si se sigue el modelo del Protocolo de Kyoto, los esquemas de límite y comercio tampoco reducirán las pérdidas de biodiversidad porque no considerarán al crecimiento económico. En respuesta a estas fallas para limitar el crecimiento económico, las organizaciones profesionales preocupadas por la conservación de la biodiversidad deberían emitir declaraciones sobre su posición respecto a umbrales ecológicos y de crecimiento económico. Las declaraciones luego pueden ser usadas por políticos para infundir estas posiciones en el proceso ciencia ambiental-política a nivel local, nacional e internacional cuando estos esquemas estén siendo desarrollados. La infusión de lenguaje que demanda la limitación de actividades de crecimiento económico con base en umbrales ecológicos es ciencia de la conservación sólida. Más notablemente, las declaraciones de posición tienen un mayor potencial para reducir las pérdidas de biodiversidad si son creadas y publicadas que si esta información permanece dentro de las organizaciones profesionales porque existe el potencial para que estas ideas se constituyan en leyes y políticas. [source] Uganda: No More Pro-poor Growth?DEVELOPMENT POLICY REVIEW, Issue 1 2005Robert Kappel This article explores changing growth regimes in Uganda, from pro-poor growth in the 1990s to growth without poverty reduction, actually even with a slight increase in poverty, after 2000. Not surprisingly, it finds that good agricultural performance is the key determinant of direct pro-poor growth in the 1990s, while lower agricultural growth is the root cause of the recent increase in poverty. At the same time, after 2000 low agricultural growth appears to have induced important employment shifts out of agriculture, which have dampened the increase in poverty. The article also assesses the indirect form of pro-poor growth by analysing the incidence of public spending and the tax system, and finds that indirect pro-poor growth has been achieved to only a limited extent. [source] Advanced microscopic imaging methods to investigate cortical development and the etiology of mental retardationDEVELOPMENTAL DISABILITIES RESEARCH REVIEW, Issue 4 2005Tarik F. Haydar Abstract Studies on human patients and animal models of disease have shown that disruptions in prenatal and early postnatal brain development are a root cause of mental retardation. Since proper brain development is achieved by a strict spatiotemporal control of neurogenesis, cell migration, and patterning of synapses, abnormalities in one or more of these events during prenatal development can lead to cognitive dysfunction after birth. Many of underlying causes of mental retardation must therefore be studied in developing brains. To aid in this research, live imaging using laser scanning microscopy (LSM) has recently allowed neuroscientists to delve deeply into the complex three-dimensional environment of the living brain to record dynamic cellular events over time. This review will highlight recent examples of how LSM is being applied to elucidate both normal and abnormal cortical development. © 2005 Wiley-Liss, Inc. MRDD Research Reviews 2005;11:303,316. [source] Teaching & Learning Guide for: The Origins of the Civil WarHISTORY COMPASS (ELECTRONIC), Issue 4 2007Nicole Etcheson Author's Introduction The author argues that slavery is the root cause of the Civil War even though historians have often posited other explanations. Some other interpretations have been ideological (i.e., about the morality of slavery), others have been economic, political, or cultural. Focus Questions 1If you were to make an argument for the causes of the Civil War, what evidence or types of evidence would you want to examine? 2In what ways can the different types of arguments (ideological, economic, political, and cultural), be combined to explain the causes of the Civil War? Do such arguments exclude or reinforce each other? In what ways? Author Recommends * E. L. Ayres, In the Presence of Mine Enemies: War in the Heart of America, 1859,1863 (New York, NY: Norton, 2003). A study of two counties, one north and one south, during the end of the sectional crisis and the early Civil War. While Potter, Walther, and Wilentz offer sweeping, often political, histories, Ayres offers a microhistory approach to the sectional conflict. Although Ayres writes within the tradition of seeing cultural differences between North and South, he concludes that slavery was the issue that drove the two sections apart. * M. A. Morrison, Slavery and the American West: The Eclipse of Manifest Destiny and the Coming of the Civil War (Chapel Hill, NC: University of North Carolina Press, 1997). Views the development of the sectional crisis through the lens of Manifest Destiny. Territorial expansion drove hostility between the sections. Morrison concentrates on the political developments of the period connected to the acquisition and organization of the territories to show how the issue of slavery in the territories polarized the sections. * D. M. Potter, The Impending Crisis, 1848,1861 (New York, NY: Harper & Row, 1976). The most comprehensive survey of the decade before the war. Potter traces the development of slavery as a political issue that North and South could not resolve. While it is a masterly and nuanced treatment of the political history, it does not incorporate social history and is more detailed than is useful for most undergraduates. E. H. Walther, The Shattering of the Union: America in the 1850s (Wilmington, Scholarly Resources, 2004) has recently supplanted Potter as a survey of the decade. It is an easier read for undergraduates and incorporates the new literature than has emerged since Potter wrote. * S. Wilentz, The Rise of American Democracy: Jefferson to Lincoln (New York, NY: Norton, 2005). A sweeping history of the United States from the constitutional era to the outbreak of the Civil War. Wilentz attempts to update Arthur M. Schlesinger Jr.'s synthesis The Age of Jackson by returning to a focus on the evolution of democracy while at the same time incorporating the social history that emerged after Schlesinger wrote. Only the last third of this very long book covers the 1850s, but Wilentz argues that democracy had taken differing sectional forms by that period: a free-labor version in the North and a plantation version in the South. Online Materials 1. The Valley of the Shadow: Two Communities in the American Civil War (http://valley.vcdh.virginia.edu/) A prize-winning website that profiles Augusta County, Virginia and Franklin County, Pennsylvania. Material from this website formed the basis of Ayres, In the Presence of Mine Enemies. Although the website primarily concentrates on the Civil War itself, it provides access to newspapers and letters and diaries from the 1850s that show the development of, and reaction to, the sectional crisis in those counties. It also shows students the types of materials (census, tax, and church records as well as newspapers and letters and diaries) with which historians work to build an argument. 2. American Memory from the Library of Congress (http://memory.loc.gov/ammem/index.html) Although not specifically devoted to the origins of the Civil War, the American Memory site provides access to the collections of the Library of Congress which contain massive amounts of primary materials for students and scholars. From the website, one can gain access to congressional documents, periodicals from the 1850s, nineteenth-century books, music, legal documents, memoirs by white and black southerners as well as slave narratives. Sample Syllabus Nicole Etcheson's ,Origins of the Civil War,' History Compass, 3/1 (2005), doi:10.1111/j.1478-0542.2005.00166.x can be used as a reading in any Civil War course. [source] Isolating the root cause of propagated oscillations in process plantsINTERNATIONAL JOURNAL OF ADAPTIVE CONTROL AND SIGNAL PROCESSING, Issue 4 2005Xiaoyun Zang Abstract Oscillations are a common type of propagated disturbance, whose sources might be attributable to a number of different phenomena such as poor controller tuning or actuator nonlinearity. A number of data-driven methods have already been proposed to isolate the source loop of nonlinearity induced plant-wide oscillations. Amongst these the bi-amplitude ratio index, correlation dimension, maximal Lyapunov exponent, nonlinearity index and spectral ICA show promise. The propagation of oscillations is first examined in order to gain an understanding of how this might affect the performances of the various techniques. The various methods are then described and their performance on a set of simulation generated data and two industrial case studies are compared. Copyright © 2004 John Wiley & Sons, Ltd. [source] The Financial Crisis: Causes and Lessons,JOURNAL OF APPLIED CORPORATE FINANCE, Issue 3 2010Kenneth E. Scott The author argues that the root cause of the recent crisis was a housing bubble whose origins can be traced to loose monetary policy and a government housing policy that continually pushed for lower lending standards to increase home ownership. The negative consequences of such policies were amplified when transmitted throughout the financial system by financial institutions through the process of securitization. In attempting to assess culpability for the crisis and identify possible reforms, the author focuses on three categories: 1Defects in Financial Products: Without criticizing derivatives and the process of securitization, the author identifies the sheer complexity of the securities as a major source of the problem,for which the solution is a simpler security design combined with greater disclosure about the underlying assets being securitized. 2Defects in Risk Management: Thanks in large part to agency and other incentive problems, there was universal underestimation of risks by mortgage originators and financial institutions throughout the securitization chain. Changing incentive pay structures is part of the solution, and so are better accounting rules for SPEs. But more effective regulatory oversight and ending "too big to fail" may well be the only way to curb excessive private risk-taking. 3Defects in Government Policy and Regulation: While acknowledging the need for more effective oversight, the author argues that there was ample existing authority for U.S. regulators to have addressed these issues. Lack of power and authority to regulate was not at the heart of the problem,the real problem was lack of foresight and judgment about the unexpected. After expressing doubt that regulators can prevent major financial failures, the author recommends greater attention to devising better methods of resolving such failures when they occur. One of the main goals is to ensure that losses are borne not by taxpayers but by private investors in a way that maintains incentives for market discipline while limiting spillover costs to the entire system. [source] On unifying multiblock analysis with application to decentralized process monitoringJOURNAL OF CHEMOMETRICS, Issue 9 2001S. Joe Qin Abstract Westerhuis et al. (J. Chemometrics 1998; 12: 301,321) show that the scores of consensus PCA and multiblock PLS (Westerhuis and Coenegracht, J. Chemometrics 1997; 11: 379,392) can be calculated directly from the regular PCA and PLS scores respectively. In this paper we show that both the loadings and scores of consensus PCA can be calculated directly from those of regular PCA, and the multiblock PLS loadings, weights and scores can be calculated directly from those of regular PLS. The orthogonal properties of four multiblock PCA and PLS algorithms are explored. The use of multiblock PCA and PLS for decentralized monitoring and diagnosis is derived in terms of regular PCA and PLS scores and residuals. While the multiblock analysis algorithms are basically equivalent to regular PCA and PLS, blocking of process variables in a large-scale plant based on process knowledge helps to localize the root cause of the fault in a decentralized manner. New definitions of block and variable contributions to SPE and T,2 are proposed for decentralized monitoring. This decentralized monitoring method based on proper variable blocking is successfully applied to an industrial polyester film process. Copyright © 2001 John Wiley & Sons, Ltd. [source] Phonological recoding deficit in working memory of dyslexic teenagersJOURNAL OF RESEARCH IN READING, Issue 1 2000Sue Palmer The picture span performance of developmental dyslexic teenagers (mean age 14 years 1 month) was compared to the picture span performance of both RA (mean age 9 years 0 month) and chronological age match controls (mean age 14 years 1 month). Three stimulus lists were manipulated for visual and phonological similarity. Findings indicated that all three groups showed a significant phonological similarity effect but only the dyslexic group showed a significant visual similarity effect. The presence of dual visual-verbal coding is postulated to be responsible for the ,noisy' encoding which others (e.g. Johnston and Anderson, 1998; Swan and Goswami, 1997) have suggested is a root cause of dyslexia. The results are discussed in terms of developmental deficits in the central executive of the working memory system. [source] Medical students' errors in pharmacotherapeuticsMEDICAL EDUCATION, Issue 3 2000Boreham Objectives This study analysed the errors made by 16 final-year medical students in a classroom prescribing exercise. The aim was to gain greater understanding of the reasons for non-optimal prescribing and of how to improve basic training in pharmacotherapeutics. Methods The task was to adjust a patient's phenytoin sodium dosage to achieve better control of seizures. It was based on a real-life case, and was presented as a written exercise. Process-tracing and think-aloud techniques were used to study the students' performance. Results The results suggest that the root cause of the errors was lack of a knowledge base which integrated scientific knowledge with clinical know-how. Three different clinical reasoning strategies were observed. Students who followed an incremental strategy demonstrated superior scientific knowledge and this resulted in less hazardous errors. Those who followed gambling or backward-reasoning strategies appeared to possess inferior scientific knowledge and this resulted in more hazardous errors. Conclusions The results support current trends towards integrating basic medical science into a foundation of clinical know-how, as in the problem-based curriculum. They also emphasize the importance of a thorough grounding in medical science as a means of minimizing error. [source] The prevalence of suppression in amblyopic individualsOPHTHALMIC AND PHYSIOLOGICAL OPTICS, Issue 1 2008Brendan Barrett Purpose:, A popular view of visual functioning in individuals with amblyopia is that the weaker eye is suppressed in key regions of the binocular visual field. Indeed, some have argued that chronic interocular suppression may represent the cause of amblyopia. Here we evaluate the prevalence of amblyopic-eye suppression in a simple light detection task when the eyes are open, minimally dissociated and in their habitual motor position. Methods:, A custom program on the Humphrey Field Analyzer (Carl Zeiss Meditec Inc., Dublin, CA, USA) was used to measure detection thresholds for a blue light on a yellow background along the horizontal meridian at two-degree intervals to an eccentricity of 25 degrees on either side of the fixation mark. The fellow eye was prevented from seeing the target using three different methods: (1) full-occlusion (i.e. no light entered the fellow eye), (2) a translucent occluder (3) a yellow filter in front of the fellow eye. In (3), the yellow filter only prevented the fellow eye from seeing the blue stimulus; the fixation mark and the background remained visible (minimal-dissociation condition). Fourteen amblyopes participated in the study, of whom 11 had strabismus. Results:, Three basic patterns of results were observed. (1) Only three of the fourteen participants (,21%) showed evidence of suppression, where amblyopic-eye sensitivity was lower with the fellow eye open. In these cases, the retinal locations that showed greatest suppression corresponded to the direction and angle of the strabismus. (2) Three participants (,21%) showed the opposite effect to the result in (1); i.e. amblyopic-eye sensitivity was greatest when the fellow was open with minimal dissociation between the eyes. One possible explanation is that the dominance of the fellow eye caused this reduction. (3) Seven participants (50%) exhibited patterns of amblyopic sensitivity that did not depend upon the occlusion status of the fellow eye. The results for one participant did not fit into any of the above patterns. Conclusions:, Suppression appears not to be a universal feature of central amblyopic vision. Our results for this simple detection task suggest that suppression may exist in as few as 20% of amblyopes. These results present a challenge to the view that suppression represents a root cause of amblyopia but they are consistent with the view that the amblyopic eye makes a useful contribution under habitual viewing conditions. [source] Nonadherence as a predictor of antidiabetic drug therapy intensification (augmentation),PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue 9 2004Dr Stephen J. Kogut MBA Abstract Purpose To determine if nonadherence with antidiabetic drug therapy is predictive of subsequent antidiabetic drug therapy intensification. Methods We conducted a retrospective cohort study examining retail pharmacy dispensings of sulfonylureas or metformin to 1067 patients having diabetes. Patients that did not receive a sufficient quantity of medication to cover at least 80% of days during the evaluation period were classified as nonadherent. Outcomes identified were increase in the dose of antidiabetic medication utilized, the addition of a second antidiabetic agent to the regimen or either. Results Among users of sulfonylurea monotherapy, those classified as nonadherent were 45% more likely to intensify therapy in subsequent months as compared with those classified as adherent (age-adjusted odds ratio (OR) 1.45; 95% confidence interval (CI) 1.06,2.00). This finding was largely driven by observed increases in dosage, which were more likely among patients classified as nonadherent (age-adjusted OR 1.48, 95%CI 1.07,2.05). Nonadherence was not found to be predictive of the subsequent addition of a second antidiabetic agent (OR 1.02; 95%CI 0.64,1.63). Overall findings were similar for the smaller sample of patients receiving metformin monotherapy, though observed differences did not achieve statistical significance. Conclusions Patients who were poorly adherent to oral antidiabetic drug therapy more frequently experienced an increase in the dose of medication prescribed, as compared to patients that were classified as adherent. This finding underscores the need for prescribers to consider nonadherence as a root cause when patients fail to achieve therapeutic goals. Copyright © 2004 John Wiley & Sons, Ltd. [source] Investigation of the relationships between die build up and die swellPOLYMER ENGINEERING & SCIENCE, Issue 2 2009Todd A. Hogan Die build up (DBU) is a common problem encountered during extrusion of polymers where material accumulates around the die exit and may cause defects in the surface of the product. This study was initiated to better understand the fundamental relationships between DBU and die swell. The study was conducted on a strand die extrusion system using an ethylene-octene polyolefin elastomer resin. This study demonstrated that die swell is not a root cause of DBU. It was shown that at constant shear rate, increasing the die L/D ratio results in an increase in DBU, while die swell decreases. The important variables influencing DBU for the resin used in this study were: the shear rate or shear stress in capillary portion of the die, the nominal residence time that the resin is exposed to the high shear stress in the die capillary, and the concentration of oligomers present in the resin or generated during processing. These data support the conclusion that DBU is due to the shear-induced migration of oligomeric species in the polymer to the die surface. Higher shear rates and stresses in the die promote this migration and result in a higher concentration of oligomeric species near the die wall. POLYM. ENG. SCI., 2009. © 2008 Society of Plastics Engineers [source] Reactive chemicals emergency response and post-event calorimetric testingPROCESS SAFETY PROGRESS, Issue 1 2010David Frurip Abstract A serious upset in process conditions may result in a Reactive Chemicals incident. In such an emergency, procedures must be implemented to prevent injuries, mitigate the event and minimize property loss and/or environmental release as dictated by the required facility Emergency Plan. This article describes the process the Dow Chemical Company uses for engaging Reactive Chemicals experts in an emergency situation. In order to be effective, the Reactive Chemicals expert must have or be provided with in-depth knowledge of the process streams and raw materials involved. The information is crucial for understanding what is happening, what might happen in the immediate future, and what can be done to successfully mitigate the Reactive Chemicals incident. Following the incident, calorimetric experiments are typically performed to confirm or refute the hypotheses of what caused the event; additionally, the experiments provide information as to reactive chemicals hazards that may potentially still exist in the process streams. The aforementioned process will be illustrated by describing an actual event. Useful methods are described and recommended for (a) characterizing and storing reactive chemicals, and (b) responding and mitigating safety incidents with reactive chemicals. The role of a reactive chemicals "expert" during and after a plant emergency is important and potentially critical to the safe handling of an ongoing event and also in determining the root cause of the incident. © 2009 American Institute of Chemical Engineers Process Saf Prog, 2010 [source] Use root cause analysis to understand and improve process safety culturePROCESS SAFETY PROGRESS, Issue 4 2008Ian S. Sutton Abstract This article describes the topics of root cause analysis and company culture. An evaluation of the root causes of incidents can help identify areas where the culture requires improvement. In addition, an analysis of the nature of root cause can help companies understand their culture. Following an incident, root cause analysis can be conducted for at least four levels of management, (a) line supervision, (b) facility management, (c) executive management, and (d) professionals who write and then implement regulations and standards. This article makes a distinction between root causes for occupational losses and for major process accidents; it emphasizes the teachings that improve one does not automatically improve the other. In other words, a root cause analysis program that addresses the behaviors that correct occupational safety problems may not help correct those behaviors that cause process safety incidents. Examples of how root cause analysis can help a company understand and improve its culture are provided. For instance, companies should recognize the need for both training and education. If process risk is to be reduced, employees need to be educated as well as trained because education creates new behaviors that allow for improved root cause analysis and the aversion of major events. © 2008 American Institute of Chemical Engineers Process Saf Prog 2008 [source] Constitution-making in Africa: assessing both the process and the contentPUBLIC ADMINISTRATION & DEVELOPMENT, Issue 2 2001M. Ndulo This article examines the relationship between governance and development, and concludes that underlying the litany of Africa's development problems is a crisis of governance. Good governance would result in institutions that are more likely to adopt economic policies that would resolve the constraints that hinder economic development. In addition, it would make a major contribution to the reduction of war and conflict. It would do this by creating an environment for sustainable development to take place and thereby reduce poverty, the root cause of war and conflict. This calls for a critical examination of the question of governance in Africa with a view to identifying the obstacles to its establishment and the possible approaches to the development of systems of governance that give political space to all groups. Since the most important legal instrument in the scheme of good governance is the national constitution, the article seeks to identify some of the key issues that must be considered in the process of developing a national constitution if it is to be durable. It also addresses the conditions under which such constitutions should be developed if they are to be acceptable to the people of the country they are intended to govern. Running through the article is the theme that the establishment of good governance in Africa depends on the development of political systems that give people a sense of ownership of the political process. Copyright © 2001 John Wiley & Sons, Ltd. [source] Identifying the time of polynomial drift in the mean of autocorrelated processesQUALITY AND RELIABILITY ENGINEERING INTERNATIONAL, Issue 5 2010Marcus B. Perry Abstract Control charts are used to detect changes in a process. Once a change is detected, knowledge of the change point would simplify the search for and identification of the special ause. Consequently, having an estimate of the process change point following a control chart signal would be useful to process engineers. This paper addresses change point estimation for covariance-stationary autocorrelated processes where the mean drifts deterministically with time. For example, the mean of a chemical process might drift linearly over time as a result of a constant pressure leak. The goal of this paper is to derive and evaluate an MLE for the time of polynomial drift in the mean of autocorrelated processes. It is assumed that the behavior in the process mean over time is adequately modeled by the kth-order polynomial trend model. Further, it is assumed that the autocorrelation structure is adequately modeled by the general (stationary and invertible) mixed autoregressive-moving-average model. The estimator is intended to be applied to data obtained following a genuine control chart signal in efforts to help pinpoint the root cause of process change. Application of the estimator is demonstrated using a simulated data set. The performance of the estimator is evaluated through Monte Carlo simulation studies for the k=1 case and across several processes yielding various levels of positive autocorrelation. Results suggest that the proposed estimator provides process engineers with an accurate and useful estimate for the last sample obtained from the unchanged process. Copyright © 2009 John Wiley & Sons, Ltd. [source] Total System Reliability: Integrated Model for Growth and Test TerminationQUALITY AND RELIABILITY ENGINEERING INTERNATIONAL, Issue 4 2005John Donovan Abstract Reliability demonstration testing is not the most efficient method of assuring product reliability prior to shipment. It is costly, time consuming and has inherent technical and social limitations. The dilemma facing the reliability and quality engineer is whether to continue demonstration testing and risk shipping a product late or ship the product and risk warranty and field service returns. Either option can cause the company to lose significant market share and profit. This paper sets out to solve this dilemma by meeting both the time to market constraints and the product reliability goals. The weaknesses of existing reliability demonstration techniques are explored and a comprehensive methodology is introduced involving controlled development processes, stress testing, root cause determination and process change feedback mechanisms. All prototype products are manufactured on the final volume process line resulting in the early identification and correction of process-related problems. Testing commences on the first available prototypes with system stress/robust testing being employed to stimulate failures, determine their root cause and correct them. Reliability growth modelling assesses the ongoing improvements occurring in reliability during the development cycle, while a statistical stopping rule is used to determine the optimal product release time without risking product warranty. The approach is applicable to systems incorporating both hardware and software elements. The methodology has been validated on three development projects of telecommunication systems comprising hardware and software. In addition to enhancing team behaviour and performance, the development times have been reduced by 14% and the ramp-up time to full worldwide product shipments has been reduced by 50%. Copyright © 2005 John Wiley & Sons, Ltd. [source] The efficacy of a test and ESS programQUALITY AND RELIABILITY ENGINEERING INTERNATIONAL, Issue 2 2002Asaf Katz Abstract Statistical results of all the 1621 failure analyses, which cover a four-year effort, are presented. The failure analyses were part of an elaborate test and ESS process of a high-reliability system. Of the failure analyses, 97.5% identified the root cause. The classification of the failures by 11 root cause classes, including the test and ESS process itself is provided. The distribution of failure root causes detected during the various phases of the process is shown. Each test phase was analyzed according to the share of failures found and the fraction of failures that occurred during that phase. Applying a linear formula that summarizes the relative efficacy of each test phase compares the performances of the various phases. The term efficacy is used to describe the ability of a test phase to reveal failures without generating new problems. Copyright © 2002 John Wiley & Sons, Ltd. [source] Process improvement evaluation approach using flow diagramsQUALITY ASSURANCE JOURNAL, Issue 3 2006Paul C. Constant Jr. Abstract Maintaining company processes will afford optimum operation and enhance the company's quality management system. A vital part of maintaining processes is their periodic evaluation. An important part of the monitoring and evaluation process is the flow diagram. A detailed flow diagram is an important tool that affords ease in visualizing the total process and is an aid in locating problem areas. The evaluation of a process is broken down into 15 steps. These steps cover gathering pertinent information, such as problem symptoms from knowledgeable sources and carrying these through their route to potential problem areas to the problems, potential causes, and the root cause of the problem. Knowing the problems brings about the need to assess their impact on the process operation as well as what changes to the process are needed and what impact these changes will have on the product , its improved quality and cost , and other vital information, such as, production rate increase, competition status, and company image. With this information, the appropriate changes are made according to a process change action plan. The plan is executed, and the process is continuously monitored according to a monitoring and evaluation plan. The paper ends with conclusions. Copyright © 2006 John Wiley & Sons, Ltd. [source] The Asian Financial Crisis: An East Asian PerspectiveASIAN-PACIFIC ECONOMIC LITERATURE, Issue 1 2000Jesus P. Estanislao Two views dominate the academic discussion of the root cause of the Asian crisis: the ,panic-illiquidity' view and the ,moral hazard-structural' view. This paper traces the factors that contributed to the build-up of financial vulnerabilities across the affected economies and compares these two accounts of the crisis. The paper argues that the two views are complementary in that policy prescriptions derived from one that disregard the prescriptions from the other would be incomplete. It summarises the medium and long-term post-crisis policy directions at the national, regional and international levels. [source] Control of misincorporation of serine for asparagine during antibody production using CHO cellsBIOTECHNOLOGY & BIOENGINEERING, Issue 1 2010Anurag Khetan Abstract A recombinant monoclonal antibody produced by Chinese hamster ovary (CHO) cell fed-batch culture was found to have amino acid sequence misincorporation upon analysis by intact mass and peptide mapping mass spectrometry. A detailed analysis revealed multiple sites for asparagine were being randomly substituted by serine, pointing to mistranslation as the likely source. Results from time-course analysis of cell culture suggest that misincorporation was occurring midway through the fed-batch process and was correlated to asparagine reduction to below detectable levels in the culture. Separate shake flask experiments were carried out that confirmed starvation of asparagine and not excess of serine in the medium as the root cause of the phenomenon. Reduction in serine concentration under asparagine starvation conditions helped reduce extent of misincorporation. Supplementation with glutamine also helped reduce extent of misincorporation. Maintenance of asparagine at low levels in 2,L bench-scale culture via controlled supplementation of asparagine-containing feed eliminated the occurrence of misincorporation. This strategy was implemented in a clinical manufacturing process and scaled up successfully to the 200 and 2,000,L bioreactor scales. Biotechnol. Bioeng. 2010;107: 116,123. © 2010 Wiley Periodicals, Inc. [source] Application of Multivariate Data Analysis for Identification and Successful Resolution of a Root Cause for a Bioprocessing ApplicationBIOTECHNOLOGY PROGRESS, Issue 3 2008Alime Ozlem Kirdar Multivariate Data Analysis (MVDA) can be used for supporting key activities required for successful bioprocessing. These activities include process characterization, process scale-up, process monitoring, fault diagnosis and root cause analysis. This paper examines an application of MVDA towards root cause analysis for identifying scale-up differences and parameter interactions that adversely impact cell culture process performance. Multivariate data analysis and modeling were performed using data from small-scale (2 L), pilot-scale (2,000 L) and commercial-scale (15,000 L) batches. The input parameters examined included bioreactor pCO2, glucose, lactate, ammonium, raw materials and seed inocula. The output parameters included product attributes, product titer, viable cell density, cell viability and osmolality. Time course performance variables (daily, initial, peak and end point) were also evaluated. Application of MVDA as a diagnostic tool was successful in identifying the root cause and designing experimental conditions to demonstrate and correct it. Process parameters and their interactions that adversely impact cell culture performance and product attributes were successfully identified. MVDA was successfully used as an effective tool for collating process knowledge and increasing process understanding. [source] Conflict-induced Displacement and Involuntary Resettlement in Colombia: Putting Cernea's IRLR Model to the TestDISASTERS, Issue 3 2000H.C.R. Muggah This paper tests Cernea's (1997) impoverishment risks and livelihood reconstruction (IRLR) model in cases of conflict-induced displacement (CID). In applying the model to a situation involving internal conflict, the article illustrates the particular problems encountered by internally displaced people (IDPs) and policymakers charged to respond to them. The article searches for local interpretations of CID and resettlement through a comparative profile of two IDP settlements in Colombia: one urban, the other rural. It concludes that the IRLR model, when contextualised, provides a useful tool to identify and categorise risks of impoverishment and resettlement priorities. At the same time, however, the article demonstrates that the model insufficiently captures the root causes or causality of CID. [source] Management system failures identified in incidents investigated by the U.S. Chemical Safety and Hazard Investigation Board,PROCESS SAFETY PROGRESS, Issue 4 2004Angela S. Blair PE, Chemical Incident Investigator A key mission of the US Chemical Safety and Hazard Investigation Board (CSB) is to determine the root causes of incidents, report the findings, and issue recommendations to prevent similar incidents from occurring. CSB investigators respond to a variety of events occurring in a wide range of workplaces, from chemical plants and refineries to food-flavoring factories and steel mills. The details of each investigation are unique and the root causes are pertinent to each specific case. However, a common thread that emerges in CSB investigations is the inadequacy of management systems that might have prevented the incident from occurring. Examples of the systemic issues identified in CSB reports are: Lack of hazard review to predict and prevent incidents Insufficient investigation and follow-up after previous incidents Inadequate training of staff Failure to implement effective mechanical integrity programs These issues are well recognized as elements of a process safety management (PSM) program, although many incidents investigated by the CSB occurred at facilities that are not regulated by OSHA's process safety management rule.1 Indeed, a number of these incidents occurred at facilities that are well outside society's definition of "chemical plants." Please note that the opinions and conclusions expressed in this paper are those of the author, and do not necessarily represent the opinions of the Chemical Safety and Hazard Investigation Board. © 2004 American Institute of Chemical Engineers Process Saf Prog, 2004 [source] The efficacy of a test and ESS programQUALITY AND RELIABILITY ENGINEERING INTERNATIONAL, Issue 2 2002Asaf Katz Abstract Statistical results of all the 1621 failure analyses, which cover a four-year effort, are presented. The failure analyses were part of an elaborate test and ESS process of a high-reliability system. Of the failure analyses, 97.5% identified the root cause. The classification of the failures by 11 root cause classes, including the test and ESS process itself is provided. The distribution of failure root causes detected during the various phases of the process is shown. Each test phase was analyzed according to the share of failures found and the fraction of failures that occurred during that phase. Applying a linear formula that summarizes the relative efficacy of each test phase compares the performances of the various phases. The term efficacy is used to describe the ability of a test phase to reveal failures without generating new problems. Copyright © 2002 John Wiley & Sons, Ltd. [source] | ||||||||||||||||||||||||||||