Documentation Errors

Such errors include mis-reading certificate or report data supplied by the producers, using secondary information from catalogs and/or literature listings, and reporting incorrect data. For the correct use of a RM/CRM, it is essential to read the information that accompanies the product once an appropriate RM/CRM has been obtained. The only reliable source of information is the Certificate of Analysis or Report of Assigned Values issued with the RM/CRM, and it must be the most up to date version available. Failure to follow a producer s recommendation will invariably result in error. 

Unfortunately, these rather basic errors are distressingly common, yet cause much unnecessary dissatisfaction. No printer is perfect, and relying on catalog data can result in the publication of incorrect data in a paper. This occurred, e.g. in 1994 when data was taken from an out-of-date NIST catalog, rather than the appropriate certificate. Published in the Journal of Analytical Atomic Spectroscopy, the paper by Soares et al. (1994) cited a certified value for Cr in NIST SRM 1548, when consultation of the Certificate would have shown that for several technical reasons the element value reported could not be certified. 

Supplementary information on many RMs/CRMs may also exist in the form of publications in the open literature, describing their production and recommended uses. That information should also be consulted by the users. But users must be aware that some values reported in these publications are indicative only and may lack the complete evaluation of data that eventually forms the certified value. Even more caution is advisable when data compilations are used in lieu of certified values. For many years a cobalt value in SRM lyjj, Bovine Liver, was propagated in this way at about 120 % of the true value. 

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A deviation is a completed event not conforming with the validation plan or validation procedures. It may include documentation errors, test results not meeting the acceptance criteria, or deviations to a procedure. 

FD-483 Citation 2 Documentation in batch records is not always accurate. Additionally, the verification check by a second production employee (usually a supervisor) failed to detect the documentation error. 

Number of times work is recycled between subprocesses and departments Number of document errors Customer satisfaction ratings Number of routing errors Value-adding processing time Information processing errors... 

Evaluates and investigates past incidents or accidents Uses risk management to control losses Satisfied with reducing accident recurrence Disciplines unsafe actions and behaviors Accepts some losses if not too severe Documents errors and primary causes Responsive to formal culture expectations Leaders delegate responsibilities to others... 

Ardizzone et al. (2002) documented errors in landslide inventory mapping in a nearly 300 km drainage basin in northern Italy performed by three groups of qualified geomorphologists. The mismatch of landslide boundaries between pairs... 

They will document error bars on datasets including images so that others can use them with confidence. They will be able to suggest simulations to test or resolve multiple reasonable hypotheses of mechanisms and use up-to-date data from others in those simulations. 

Analyzes to determine root causes Documents errors and primary causes... 

The Notice of Errors. The first mechanism for correction of errors is called a "Notice of Errors." This document may be filed by the patentee after issuance of the patent with the U.S. PTO and references the patent number, issue date, and the errors contained in the patent. The purpose of a Notice of Errors is to clarify the examination history of the patent and such notice dispositively corrects any misspellings, or typographical errors or omissions. One example of a problem which may be clarified by a Notice of Errors is an omitted chemical bond in a compound used in an exemplary embodiment of the invention. In short, the error is obvious and easily corrected. 

Quality Audit. Another important responsibiUty of quahty assurance is the audit function. Using the quahty audit as a tool, QA can monitor the operation of the manufacturing faciUty a toU, ie, contract, manufacturer or raw material suppHer to assure that written procedures are in place and that there is documentation to indicate the procedures are being followed. Properly executed audits allow QA to spot potential weakness in the quahty system that could allow errors to occur. Once identified, these weaknesses can then be corrected before they result in nonconformance. 

The period covered by the published accounts of a company is usually 1 year, but the details from which these accounts are compiled are entered daily in a journal. The journal is a chronological listing of every transaction of the business, with details of the corresponding income or expenditure. For the smallest businesses, this may provide sufficient documentation, but in most cases the unsystematic nature of the journal can lead to computational errors. Therefore, the usual practice is to keep accounts that are listings of transactions related to a specific topic such as purchase-of-oil account. This account would list the cost of each purchase of oil, together with the date of purchase, as extracted from the journal. 

You should consider obtaining internal and external quality assurance reviews of the study (to ferret out errors in modeling, data, etc.). Independent peer reviews of the QRA results can be helpful by presenting alternate viewpoints, and you should include outside experts (either consultants or personnel from another plant) on the QRA review panel. You should also set up a mechanism wherein disputes between QRA team members (e.g., technical arguments about safety issues) can be voiced and reconciled. All of these factors play an essential role in producing a defendable, high-quality QRA. Once the QRA is complete, you must formally document your response to the project team s final report and any recommendations it contains. 

The confusion matrix (NSAC-60) is a method that identifies potential operator errors lemming from incorrect diagnosis of an event. It can be used to identify the potential for an operator to conclude that a small LOCA has occurred, when it is actually a steam line break. This provides a method for identifying a wrong operator response to an off-normal plant condition. It is particularly useful in Step 5 of the. SHARP procedures, Documentation requirements are presented in Table 4.5-2. 

The paired comparisons method (NUREG/CR-3688) is a structured expert judgment method in which human errors are compared in pairs. By combining the judgments of the group of experts, the errors arc arranged in order of likelihood of occurrence, of the human errors considered, they can be used as "anchor points list. Documentation requirements are given in Table 4.5-8. 

I am particularly indebted to Dr. Howard Lambert of Lawrence Livermore Laboratory and FfA Associates for providing the PC computer codes FTAP (fault ti ee code), POSTER (post processor), IMPORT (importance calculation), MONTE (Monte Carlo error determinadoni, and supporting documentation and instructions. 

The required exposure times are difficult to estimate. They are best found by trial and error. Documentation of fluorescence quenching at A = 254 nm usually only requires one trial. The exposure time found to be adequate here is normally suitable for all following exposures of fluorescence quenching if the exposure conditions are maintained constant (camera type, film type, distance of objective and lamp, aperture etc.). The exposure time required for fluorescent chromatograms is primarily dependent on the intensity of the fluorescence and, therefore, has to be optimized for each chromatogram. It is best to operate with a range of exposure times, e.g. aperture 8 with exposures of 15,30,60,120 and 240 seconds. Experience has shown that one exposure is always optimal. 

Instructions concerning safety and environmental issues should be integrated into the control and operating procedures such that the instructions are given at the stage in the process when they apply. In this way staff do not have to consult several documents and the chance of error is reduced. 

All data should be examined before use, otherwise you may inadvertently introduce errors into your work. The standard does not require that data controls be the same as document controls so you are at liberty to pitch the degree of control appropriate to the consequences of failure. 

If you operate a computerized documentation system, your problems can be eased by the versatility of the computer. Using a database you can provide users with all kinds of information regarding the nature of the change, but be careful. The more you provide the greater the chance of error and the harder and more costly it is to maintain. 

Where you devise original solutions to the measurement of characteristics the theory and development of the method should be documented and retained as evidence of the validity of the measurement method. Any new measurement methods should be proven by rigorous experiment to detect the measurement uncertainty and cumulative effect of the errors in each measurement process. The samples used for proving the method should also be retained so as to provide a means of repeating the measurements should it prove necessary. 

Rework means the continuation of processing that will make an item conform to specification. Rework requires only normal operations to complete the item and does not require any additional instructions. Rework when applied to documents means correcting errors without changing the original requirement. 

Documentation checks are vital at this stage since you are being judged on your on-time shipment performance. A delay caused by an error in the ASN will jeopardize all your hard work to meet the shipment date. The system that prints the container labels should therefore use the same data that is entered onto the ASN in order to avoid error. Eliminate human transcription errors and you are halfway there. The only other action is making sure that what s in the box is what it says on the label. 

Figure 4.17 shows a useful format for documenting the results of error analysis. This is based on the HTA in Figure 4.2. For every critical error (e.g., action omitted) the implications or consequences for the system and the possibilities...

FIGURE 4.17. Documentation of the Results of Human Error Analysis... 

These errors are concerned with the transfer of information among people, either directly or via written documents such as permit systems. These errors are particularly pertinent in situations where a number of people in a team have to coordinate their activities. 

The case study has documented the investigation and root cause analysis process applied to the hydrocarbon explosion that initiated the Piper Alpha incident. The case study serves to illustrate the use of the STEP technique, which provides a clear graphical representation of the agents and events involved in the incident process. The case study also demonstrates the identification of the critical events in the sequence which significantly influenced the outcome of the incident. Finally the root causes of these critical events were determined. This allows the analyst to evaluate why they occurred and indicated areas to be addressed in developing effechve error reduchon strategies. 

In April 1982, a data workshop was held to evaluate, discuss, and critique data in order to establish a consensus generic data set for the USNRC-RES National Reliability Evaluation Program (NREP). The data set contains component failure rates and probability estimates for loss of coolant accidents, transients, loss of offsite power events, and human errors that could be applied consistently across the nuclear power industry as screening values for initial identification of dominant accident sequences in PRAs. This data set was used in the development of guidance documents for the performance of PRAs. 

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