Structure of human errors in tasks of operators working in the control room of an oil refinery unit

Niloufar Shah Gholi-Nejad

doi:10.17485/ijst/2012/v5i2.11

Abstract

In the present research, human errors existed in tasks of operators working in two control rooms (Northern and Southern control rooms) in the Tehran oil refinery are identified and evaluated. Then, corrective strategies and actions are advised to decrease errors. At first, using hierarchical task analysis (HTA) method, four positions including shift controller, head operators, control room's operators, and outside operators are analyzed. Afterwards, human errors in the considered positions are identified and assessed using technique for retrospective and predictive analysis of cognitive errors (TRACEr). Results present 670 internal errors and 738 external errors in the Northern sector while 661 internal errors and 744 external errors in the Southern sector. In two sectors, this number of errors was identified for 27 major tasks and 108 minor tasks. Action errors are the most repeated errors among the internal errors while violation errors are the least. In addition, most of external errors are related to communication errors while the least errors are related to time and sequence errors. According to results of applying psychological error mechanism (PEM) in the considered positions, people's distraction is the main factor causing errors. Performance shaping factors (PFS) identifies lack of training as the major factor for errors. Using TRACEr, all external and internal errors, psychological error mechanism, and primary factors of errors in the control room can be detected.

Highlights

Human beings play critical roles in oil and Studies indicate that human errors are the direct and gas processes with high risk of fire and explosion (Zarei, indirect factors of 90% of all industrial accidents (Reason, 2009)
According to current identification of factors leading to human errors in the oil statistics, in the late 30 years, 75 out of 157 accidents in and gas industry can contribute much in improving the the oil and gas offshore facilities have led to fire, financial safety of such system and decrease in the industrial losses, and casualties equal to 3 billion dollars and 187 hazards
The present investigation focuses on human errors involved in tasks of operators working in two control rooms of units including Isomax, catalytic conversion, and hydrogen units of the Northern and Southern sectors of Tehran oil refinery

Summary

Introduction

Human beings play critical roles in oil and Studies indicate that human errors are the direct and gas processes with high risk of fire and explosion (Zarei, indirect factors of 90% of all industrial accidents (Reason, 2009). The largest recorded disaster facilities with 40 years of existence This refinery is originated from human errors is a broad fire in Britain located in south edge of metropolitan Tehran. External error task task Northern Southern Northern Southern determined This technique uses Shift controller psychological error mechanism Head operator (PEM) in tasks assigned to people Control room’s operator 5 and performance shaping factors (PSF). It presents all outside operator Total stages to identify and recover errors (RSSB, 2005; Shorrock & Kirwan, 2002).

Methodology

Results

Results of TRACEr