Fault Tree Analysis - AMOS Online PDF
Preview Fault Tree Analysis - AMOS Online
AAPM 57th Annual Meeting Fault Tree Analysis Peter Dunscombe, PhD, FCCPM, FAAPM, FCOMP Professor Emeritus University of Calgary Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Disclosure Peter Dunscombe Director, TreatSafely, LLC Director, Center for the Assessment of Radiological Sciences. Occasional Consultant to IAEA and Varian. Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Fault Tree Analysis O Ring hardened Pump fails Pressure control system fails Motor burns out Pressure release valve fails Nuclear Explosion Event Fuel rods stick Can’t retract fuel rods or Manual retraction under repair and Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Purpose of a Fault Tree Analysis To make the (radiotherapy) system safer through using postulated failure modes, tracing the failure pathways back and, on the basis of the FTA, • Identifying possible systemic program weaknesses. • Placing barriers and checks (QA and QC) Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Fault Tree Analysis Fault Tree Analyses are extensively used in high risk, high reliability industries such as the chemical, nuclear and aviation industries. Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. The AAPM’s Task Group 100 Process Mapping helps us to understand the details of the patient’s clinical pathway. Failure Modes and Effects Analysis helps us to prioritize failure modes for further analysis. Fault Tree Analysis helps us to identify: •possible systemic program weaknesses •where to put barriers and checks. Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Objectives • To appreciate the relationship between Fault Tree Analysis and Failure Modes and Effects Analysis. • To explore the similarities and differences between Fault Tree Analysis and Root Cause Analysis. • To consider TG 100’s contribution to Fault Tree Analysis. • To confirm the predictive power of Fault Tree Analysis. Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Objectives • To appreciate the relationship between Fault Tree Analysis and Failure Modes and Effects Analysis. • To explore the similarities and differences between Fault Tree Analysis and Root Cause Analysis. • To consider TG 100’s contribution to Fault Tree Analysis. • To confirm the predictive power of Fault Tree Analysis. Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. Failure Modes and Effects Analysis Failure Mode ????? Cause Potential Potential Examples of Step Major Potential Failure RP Step Causes of Effects of O S D Causes and # Processes Modes N Failure Failure Failures Wrong to very LINAC hardware Poor hardware wrong dose Wrong dose failures/wrong design affecting all patients Wrong dose dose per MU; Poor hardware treated on machine 11 - Day 1 Treatment distribution 5. 8. 7. 178 MLC leaf motions maintenance. 354 (or with affected Treatment delivered Wrong location 4 2 2 inaccurate, Inadequate beams) until Wrong volume flatness/symmetry physics QA problem is found , energy, etc process and corrected. 9 Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015. FTA in the context of FMEA Potential Potential Examples of Step Major Potential Failure RP Step Causes of Effects of O S D Causes and # Processes Modes N Failure Failure Failures Wrong to very LINAC hardware Poor hardware wrong dose Wrong dose failures/wrong design affecting all patients Wrong dose dose per MU; Poor hardware treated on machine 11 - Day 1 Treatment distribution 5. 8. 7. 178 MLC leaf motions maintenance. 354 (or with affected Treatment delivered Wrong location 4 2 2 inaccurate, Inadequate beams) until Wrong volume flatness/symmetry physics QA problem is found , energy, etc process and corrected. 10 Peter Dunscombe. Fault Tree Analysis, AAPM. 14th July 2015.
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