2now how things went wrong

... change the way people live their lives—they make things safer, easier, faster, or cheaper Knowing your stuff Technology is the science of how things work The inventors of these shoes knew that ... sticky they clump together to form drops Become an expert on how ships float, 46–47 on how airplanes fly, 52–53 43 Gases and liquids How fluids work Gases (such as air) and liquids (such as water) ... sound Light and sound Now you see it Light and bubbles Mirror,rorriM Lenses How light works Fireworks Measuring sound How ears hear Electric guitar 122–125 Glossary 126–127 Index 128 Picture credits...

Ngày tải lên: 25/12/2013, 16:34

... the information and how they it C Follow-up communication while in the hospital Communication and follow-through after discharge are considered in Section IV WHEN THINGS GO WRONG A Initial Communication: ... desire.” We must commit ourselves to relentless self-examination and continuous improvement When things go wrong, our obligation becomes two-fold: to intensify our commitment to care for the patient ... cause harm A medical error that does not cause harm does not result in an adverse event.) WHEN THINGS GO WRONG • Type 1: Error by the attending physician Example: technical error during performance...

Ngày tải lên: 07/03/2014, 10:20

... WHAT WENT WRONG IN IRELAND? Introduction and overview During the 1990s, Ireland emerged from a lengthy ... back negatively into credit availability and rising tax rates deepening the output loss What went wrong? It is an interesting boom and bust story, which combines hubris formed during the years ... heavily dependent on a continuation of the boom Two distinct growth phases To understand what went wrong it is essential to distinguish between two different growth phases Up to 2000 there was...

Ngày tải lên: 31/03/2014, 05:21

... Agency Map shows where air concentrations of sulfur dioxide, particulates, carbon monoxide, lead, ozone and nitrogen dioxide exceeded EPA standards during September 1996 The graph shows the emissions ... Other drugs shifts color when it binds to calcium, may also tackle excitotoxicity and apopZukin showed how powerfully AMPA tosis simultaneously by sweeping up receptors change character 24 to 48 certain ... energy to Europa’s interior, however If the energy flow is great enough, it might be sufficient to melt the underlying layers of ice, creating a vast ocean The Galileo images show that “there was enough...

Ngày tải lên: 12/05/2014, 15:23

... measure produced them B.L Princeton, N.J October 15, 2001 What Went Wrong? WHAT WENT WRONG? INTRODUCTION Introduction What went wrong? For a long time people in the Islamic world, especially ... Ism~‘§l until 1529, by which time the shah had been dead for five years WHAT WENT WRONG? Figure I-2 Wall painting in Isfahan, showing European visitors From the Chihil Sutun (Forty Columns) pavilions ... problem Egyptian naval expeditions against the Portuguese in eastern waters were 13 WHAT WENT WRONG? however unsuccessful and no doubt contributed to the defeat of the Egyptian sultanate in 1516–1517...

Ngày tải lên: 03/06/2014, 01:44

... that I have recently updated It considers how an absolutist condemnation of terrorism cannot be derived from a consequentialist evaluation and shows how it should also not be thought derivable ... to terrorism But we are far from agreeing on what terrorism is and how we can understand it, let alone how to respond to it and how to prevent it My judgments in this chapter are comparative I ... compare war and terrorism and to show how war can be morally worse 16 • h o w t e r r o r i s m i s w r o n g D e f i n i n g Te r r o r i s m Understanding how to define terrorism is notoriously...

Ngày tải lên: 10/06/2014, 22:20

... endurance theories account differently for many features of the world how things change, how we refer to persisting things, and how and whether persistence can be a vague matter Perdurance theory ... HOW THINGS PERSIST How things persist? Are material objects spread out through time just as they are spread ... contentious How old are you? You know how long it is since you were born, but did you exist before that? Mostly we agree that people exist before birth, but often we disagree about how long people...

Ngày tải lên: 11/06/2014, 01:05

... measure produced them B.L Princeton, N.J October 15, 2001 What Went Wrong? WHAT WENT WRONG? INTRODUCTION Introduction What went wrong? For a long time people in the Islamic world, especially ... Ism~‘§l until 1529, by which time the shah had been dead for five years WHAT WENT WRONG? Figure I-2 Wall painting in Isfahan, showing European visitors From the Chihil Sutun (Forty Columns) pavilions ... problem Egyptian naval expeditions against the Portuguese in eastern waters were 13 WHAT WENT WRONG? however unsuccessful and no doubt contributed to the defeat of the Egyptian sultanate in 1516–1517...

Ngày tải lên: 11/06/2014, 01:29

... some high risk genes identified for an individual disease However, it is unclear how these identified genes interact to other factors and how these susceptible genes are triggered by aforementioned ... these findings How to discriminate OCD characteristics from typical symptoms of GTS? How to objectively characterize expression of motor tics in GTS and GTS+OCD? And finally, how to characterize ... When Things Go Wrong – Diseases and Disorders of the Human Brain P300) (Sarason, Johnson, & Siegel, 1978) An initial study, using an auditory oddball1 paradigm, with GTS patients, has shown an...

Ngày tải lên: 28/06/2014, 11:20

... have been prevented Case histories illustrate what went wrong and why it went wrong, and then guide you in how to circumvent similar tragedies Twenty percent of the information in this fourth edition ... purpose here is to show what has gone wrong in the past and tn suggest how similar incidents might be prevented in the future Unfortunately the history of the process industries shows that many incidents ... wreckage after the fire showed that the pump suction valve was open and the drain valve shut [ ] -~ *End-of-chapter references are indicated by a number inside brackets What Went Wrong? The pump had...

Ngày tải lên: 11/08/2014, 18:20

... and no one else could have done anything to prevent it However, further investigation showed that all permits issued asked for 26 What Went Wrong? goggles to be worn, even for repairs to water ... by a gauge pressure of 470 psi (32 bar) 10 What Went Wrong? Slip-plates should normally be designed to withstand the same pressure as the piping However, in some older plants that have not been ... trying to start the equipment that has been isolated However, this system is not foolproof, as shown by the following incidents In one case the wrong circuit was isolated, but the circuit that should...

Ngày tải lên: 11/08/2014, 18:20

... error Figures 1-14 and 1-15 show how two such incidents occurred The second system is particularly vulnerable because in trying to unscrew the nuts that 36 What Went Wrong? Figure 1-13 This steel ... will never carry out repairs in a foolish or unsafe manner 1.5.4 Failure to Understand How Things Work or How They Are Constructed (a) Several spillages have occurred from power-operated valves ... 1.5.8 Who Should Decide How to Carry Out a Repair? The following report raises two interesting questions: * Who decides how a maintenance job should be carried out? = How should we clear chokes...

Ngày tải lên: 11/08/2014, 18:20

... Instructions A batch went wrong Investigation showed that the operator had charged 104 kg of one constituent instead of 104 g (0.104 kg) The instructions to the operator were set out as shown in Table ... designed so they cannot be interchanged 80 What Went Wrong? (b) With many types of screwed couplings and compression couplings, it is easy to use the wrong ring Accidents have occurred as a result ... are few signs of a similar integration in government departments 74 What Went Wrong? 2.12 CONTROL OF MODIFICATIONS How can we prevent modifications from producing unforeseen and undesirable...

Ngày tải lên: 11/08/2014, 18:20

... leaking auay from an isolated system 96 What Went Wrong? Accidents that occurred because maintenance workers did not understand how things work or how they were constructed were described in Section ... =level alarm and trip operated by low level LA LT Figure 5-4 How failure of a level controller can overpressure a tank 114 What Went Wrong? dioxide to remove the air, and the refrigerated butane ... 94 What Went Wrong? (b) A new cooler was being pressure-tested using a water pump driven by compressed air...

Ngày tải lên: 11/08/2014, 18:20

... process materials that they fail to establish and maintain proper precautions How often had the wrong 152 What Went Wrong? hose or a damaged hose been used before? Why had the foremen or the super\isors ... eliminated as a source of ignition - + + l Normal drain Figure 5-14 How to sink the roof of a floating-roof tank 126 What Went Wrong? by fitting shunts-strips of metal-about every meter or so around ... inexperienced operator; there was no low-flow alarm or high-oxygen alarm [7] The author shows commendable 140 What Went Wrong? frankness in describing the incident so that others may learn from it, but...

Ngày tải lên: 11/08/2014, 18:20

... liquids are handled or when experience shows there is a significant chance of a leak [3].Detectors are also 162 What Went Wrong? available for common toxic gases However, these detectors not away with ... 182 What Went Wrong? filled with steam coils The oil was circulated while it was being dried The suction line projected into the conical base of the tank, forming a dead-end, as shown in Figure ... Emergency isolation valves are discussed in detail in Reference 3, and the following incidents show how useful they can be They can be operated electrically, pneumatically, or in some cases, hydraulically...

Ngày tải lên: 11/08/2014, 18:20

... the point where it had started its journey Remarkably, no one was injured Four things were wrong: 202 What Went Wrong? The operating lever should have been removed before the cylinder was moved ... Drain points choked (Steam trap bypasses not shown) Figure 9-10 Arrangement of drains on steam main that was broken by water hammer 190 What Went Wrong? The operator took about one to two minutes ... tests show they are suitable (see Section 9.2.1 h) (b) Many failures have occurred because the wrong grade of steel was used for a pipeline The correct grade is usually specified but the wrong...

Ngày tải lên: 11/08/2014, 18:20

... told me to so.” What Went Wrong? 216 Inspector-: “When was your master gauge last calibrated?” M K X : “I didn’t use one.” Inspector: “You didn’t use a master gauge? Then how did you check it?’ ... was injured, fortunately not seriously 224 What Went Wrong? Fuel oil Figure 10-13 Lighting a furnace heated by heavy fuel oil When the burner went out, the solenoid valve took a few seconds to ... materials, they are then deliberately reintroduced, as in the following incidents 232 What Went Wrong? (a) Two men went into a reactor to carry out a dye-penetrant test on a new weld using trichlorethylene...

Ngày tải lên: 11/08/2014, 18:20

... Section 7.1.6, in particular because damaged hoses or hoses made from the wrong material were used However, 264 What Went Wrong? the most common cause of hose failure is the tanker driving away ... operator then went into the warehouse, selected what he thought was the other end of the projecting hose and connected it to the air line Unfortunately there were sev- 250 What Went Wrong? era1 ... connections were used for nitrogen and compressed air so it was difficult at first to see how a mistake had been made However, the place where the man was working was a long way from the nearest coinpressed...

Ngày tải lên: 11/08/2014, 18:20

... Closed cans, how- Figure 15-1 The bucket was not grounded and acquired a charge 292 What Went Wrong? ever, will not prevent ignition by static electricity, as the following incidents show (b) A ... was left in position and corroded, 299 300 What Went Wrong? causing an acid leak Subsequent checks showed that many more gaskets were made of the wrong material (b) A carbon steel valve painted ... correctly Sometimes, however, investigators have failed to find any other source of ignition So they assume that it must have been static even though they are unable to show precisely how a static charge...

Ngày tải lên: 11/08/2014, 18:20