Incident Analysis using the Root Cause (Tripod Beta) Methodology-An SPDC Experience

BackgroundMonitoring trends in lung cancer incidence and mortality is important for the evaluation of cancer control activities. We investigated recent trends in age-standardized incidence rates by histological type of lung cancer in Osaka, Japan.MethodsCancer incidence data for 1975–2008 were obtained from the Osaka Cancer Registry. Lung cancer mortality data with population data in Osaka during 1975–2012 were obtained from vital statistics. We examined trends in age-standardized incidence and mortality rates for all histological types and age-standardized incidence rates by histological type and age group using a joinpoint regression model.ResultsThe age-standardized incidence rate of lung cancer levelled off or slightly increased from 1975–2008, with an annual percentage change of 0.3% (95% confidence interval [CI], 0.1%–0.4%) for males and 1.1% (95% CI, 0.9%–1.3%) for females, and the mortality rate decreased by 0.9% (95% CI, 1.2%–0.7%) for males and 0.5% (95% CI, 0.8%–0.3%) for females. The incidence rates of squamous cell carcinoma (SQC) and small cell carcinoma (SMC) significantly decreased for both genders, whereas that of adenocarcinoma (ADC) significantly increased among almost all age groups in both genders.ConclusionsThe incidence rates of SQC and SMC decreased with the decline in smoking prevalence, which probably explains the change in trends in the incidence rates of lung cancer from the mid-1980s. However, the reason for the increase in ADC remains unclear. Therefore, trends in incidence rates of lung cancer should be carefully monitored, especially for ADC, and the associations between ADC and its possible risk factors should be studied.

Trends in breast cancer incidence, survival, and mortality

Mapping overdiagnosis of thyroid cancer in China

Increasing Incidence Rates of Colorectal Cancer at Ages 50–54 Years

Results from an engineering investigation, including findings, root cause and corrective action of an ETF40B compressor incident, are presented in this paper. Vericor’s ETF40B is used to power US NAVY Landing Craft Air Cushion (LCAC) vehicles that have undergone the Service Life Extension Program (SLEP). This paper discusses the initial review of an engine incident, the results of the engineering investigation that led to identifying root cause and the successful validation testing providing fleet corrective action. This paper will present the history of the investigation, the metallurgical analysis findings, the results of finite element stress analysis and investigative testing performed on the vane. The paper will conclude with the testing conducted to verify the design solution and how the final field and production compressor changes were incorporated.

Accidents provide important learning points to prevent future mishaps. In its approach to accident prevention one technique that Shell uses is the Tripod accident analysis tree.In the past there has been a tendency in all organisations to blame accidents on the people who suffer them and to see unsafe acts as arising from the stupidity, carelessness or recklessness of particular individuals. Accident investigations frequently cite 'human error' as the cause and many people still see such errors as the beginning and end of the accident sequence. The three more tangible components of such accident investigations are unsafe acts, failures of defences and the accidents themselves. Such unsafe acts or 'active failures' are often seen as the most important part of the accident story. In reality the story has its beginnings much earlier in areas such as Design, Procedures, Training or Maintenance Management, areas known as 'latent failures',To better understand the underlying causes of accidents, in 1988 Shell commissioned a behavioural research program called Tripod. Tripod does not address unsafe acts and hazards directly, but places them in context in a model of an accident which seeks to define the underlying organisational factors that provoke unsafe acts, and that allow errors to turn into accidents. The research has established that latent failures may be categorised into a small number of disruptive processes. These latent failures are incorporated into an accident diagram in the form of a 'tree', and improve our understanding of the causes of accidents, and direct our recommendations for improvement into areas that are likely to be the most effective.

This study aimed to assess time trends in colorectal cancer incidence from 1983 to 2012 in Latin America. This was an ecological time-series study whose population consisted of individuals aged 20 years or older diagnosed with colorectal cancer. Data from population-based cancer registries in Cali (Colombia), Costa Rica, Goiânia (Brazil), and Quito (Ecuador), were used for rates estimation, while time trends estimations were proceeded by the Joinpoint Regression Program. The study showed an increase in colorectal cancer incidence in men and women in Cali (2.8% and 3.2%, respectively), Costa Rica (3.1% and 2.1%, respectively), and Quito (2.6% and 1.2%, respectively), whereas in Goiânia, only women showed an increase in colorectal cancer rates (3.3%). For colon cancer, we observed an increasing trend in incidence rates in men and women in Cali (3.1% and 2.9%, respectively), Costa Rica (3.9% and 2.8%, respectively), and Quito (2.9% and 1.8%). For rectal cancer, we observed an increasing trend in incidence in men and women in Cali (2.5% and 2.6%, respectively), Costa Rica (2.2% and 1%, respectively), and Goiânia (5.5% and 4.6%, respectively), while in Quito only men showed an upward trend (2.8%). The study found increases in colorectal cancer, colon cancer, and rectal cancer in four Latin America regions. This findings reflect lifestyle, such as dietary changes, following the economic opening, and the prevalence variations of colorectal cancer risk factors by sex and between the four studied regions. Finally, the different strategies adopted by regions for colorectal cancer diagnosis and screening seem to influence the observed variation between anatomical sites.

This case series highlights the challenges in eye banking and the importance of a quality assurance program. Three cases triggered corrective and preventive actions (CAPAs) to improve the processes. Case 1 emphasized training to prevent retrieval failures. Case 2 stressed the need for blood samples and comprehensive documentation. In Case 3, mishandling led to policy revisions and staff training. CAPA involved identifying concerns, root cause analysis, action plans, implementation, checks, and closure. Errors can occur in man, machinery, process, and policies. Continuous CAPA ensures continuous quality improvement and safe corneal tissue transplantation, benefiting patients in need.

Failure modes and effects analysis (FMEA) is a popular reliability tool in petroleum engineering. In FMEA, potential failure modes or corrective actions are evaluated, each assigned a Risk Priority Number (RPN) score, and prioritized for decision making. FMEA is also known as Failure Modes, Effects, and Criticality Analysis (FMECA), while focuses on failure modes prioritization. Despite of the popularity of FMEA and FMECA, it is not clear, how potential failure modes and corrective actions could be represented systematically, for effective decision making. In this paper, two new representations (i.e., a tree representation and a vector representation), for potential failure modes and corrective actions, are proposed. The tree representation for a potential failure mode allows its root cause(s), effect(s) and corrective action(s), together with their severity, occurrence and detection rating(s), to be represented as a three-layer tree model. The tree representation for a corrective action with similar contents is outlined too. The RPN model, together with its score, is represented as a node of the tree model. These tree models can also be represented as their associated equivalence layered-vector representations. In this paper, the usefulness of the proposed approaches is illustrated with benchmark FMEA worksheets pertaining to petroleum engineering.

Health administrative data are a potentially efficient resource to conduct population-based research and surveillance, including trends in incidence and mortality over time. Our objective was to explore time trends in incidence and mortality for rheumatoid arthritis (RA), as well as estimating period prevalence. Our RA case definition was based on one or more hospitalizations with a RA diagnosis code, or three or more RA physician-billing codes, over 2years, with at least one RA billing code by a rheumatologist, orthopedic surgeon, or internist. To identify incident cases, a "run-in" period of 5years (1996-2000) was used to exclude prevalent cases. Crude age and sex-specific incidence rates were calculated (using data from 2001 to 2015), and sex-specific incidence rates were also standardized to the 2001 age structure of the Quebec population. We linked the RA cohort (both prevalent and incident patients) to the vital statistics registry, and standardized mortality rate ratios were generated. Negative binomial regression was used to test for linear change in standardized incidence rates and mortality ratios. The linear trends in standardized incidence rates did not show significant change over the study period. Mortality in RA was significantly higher than the general population and this remained true throughout the study period. Our prevalence estimate suggested 0.8% of the Quebec population may be affected by RA. RA incidence appeared relatively stable, and mortality was substantially higher in RA versus the general population and remained so over the study period. This suggests the need to optimize long-term RA outcomes.

Incidence rate and temporal trends in coeliac disease and coeliac disease autoimmunity incidence vary worldwide with most data available from North American and European countries. To explore temporal trends in incidence of coeliac disease autoimmunity and their relation to increase in screening tests in Israel. A large retrospective population-based study was conducted in Maccabi Healthcare Services, a 2.3-million-member health maintenance organisation operating in Israel. The cohort included all patients with newly diagnosed coeliac disease autoimmunity based on first positive anti-tissue transglutaminase type 2 IgA antibodies. Data were analysed for the years 2007-2015. During the study period (17.3 million person-years), a total of 403283 patients were tested for coeliac disease autoimmunity, of whom 6444 were positive, representing an average incidence rate of 36.64 per 100000 person-years (95% CI: 35.74-37.55). Incidence of coeliac disease autoimmunity increased from 25.4 per 100000 in 2007 to 52.3 per 100000 person-years in 2015 (Incidence rate ratio of 2.06, 95% CI 1.81-2.26). Coeliac disease autoimmunity incidence was highest in the paediatric age groups, especially in children aged 0-5, and was 4 times higher than the incidence in adults aged 26-55 (Incidence rate ratio of 0.24, 95% CI (0.22-0.26). The increase in incidence surpassed the increase in testing for new patients. Positive trends in incidence were highest in small children, whereas the incidence in adults was stable over the years. There was a steady increase in coeliac disease autoimmunity incidence in our cohort between the years 2007-2015. The paediatric population was the only contributor to this trend.

Root Cause Analysis of Product Service Failure Using Computer Experimentation Technique

Current challenges of university laboratory: Characteristics of human factors and safety management system deficiencies based on accident statistics

Summary Tripod Delta (diagnostic evaluation tool for accident prevention) is a checklist-based approach to carrying out safety "health checks." This paper describes the theoretical background of the approach, which is based on a model for understanding the role of human error in accidents. The method for constructing databases from which to make checklists and use of the system to generate remedial safety plans are described. Finally, the implementation is discussed and the status is reviewed. Introduction Tripod is an approach to safety developed by the U. of Leiden and the U. of Manchester in close cooperation with the Shell Intl. Petroleum Mij. B.V.E&P function. Tripod attacks underlying safety problems with special reference to human error, which is seen in failures at both individual and organization levels. A central concept in Tripod is the "latent failure," the potential cause of future accidents. Tripod Delta is a diagnostic tool developed to help identify such underlying problems before latent failures generate active failures (the immediate causes of accidents).This paper describes the background of Tripod Delta, how it operates, and the current status of the system. Accidents, Unsafe Acts, and Underlying Causes. Accidents have a number of immediate causes, many of which have a human origin. For an accident to take place, unsafe human acts must interact with triggering events, such as a breaking cable or a well kick. When the combination circumvents available defenses, the result may be an accident or a near miss. All too often, investigation of an incident focuses on the immediate events and human failures. This concentration on the direct causes (active failures) also often applies to proposals for prevention of future incidents. However, the events leading to accidents do not arise spontaneously. The shortcomings that can be identified after an accident are often present long before as latent failures. The general Tripod model (Fig. 1) in cludes three basic components of the accident process.Accidents happen when defenses are breached.The unfortunate sequence of events involves the combination of one or more unsafe acts in the context of specific triggering conditions (which may themselves be technical or human in origin).Behind the unsafe acts and conditions is a history of causes, classified into a limited set of general failure types (GFT's) shown in Table 1. This restricted set of 11 GFT's has been identified in field studies and from analyses of major accidents. The list was defined by providing a general set of terms adequate to describe latent failures and by distinct ways to remedy the problems identified. The communication GFT, for instance, covers both technical failures (e.g., a poor or nonexistent telephone system or difficult radio communication) and human failures (inability to pass on or to understand messages). The important factor in a potential accident is that the vital information may not be available to the proper people at the right time. Similarly, the hardware GFT refers to the quality and availability of components, tools, and equipment. Problems in any of these areas may lead people to create situations that can lead to hardware failures later, such as accepting corrosion, installing in correct material, or using the wrong tools. The view taken in Tripod is that it is more effective to concentrate on the conditions defined by the GFT's rather than to attempt to stop the unsafe acts as they occur. The GFT's behind the large numbers of unsafe acts and triggering events form a natural and more limited set of targets for improvement. Safety Management and Proactive Approaches. An important starting point in safety management involves identifying the necessary components of good management practice. Shell's Enhanced Safety Management Principles embody such an approach, stressing such factors as the necessity for a firm commitment to safety, line responsibility for safety, and regular audits. Once management systems meet such principles, it generally becomes necessary to determine where attention must be directed. P. 58^

Estimated worldwide variation and trends in incidence of lung cancer by histological subtype in 2022 and over time: a population-based study.