Technique For Human Error Analysis Research Articles

Identifying and evaluating human errors in Operating a Furnace in a Petrochemical Industry Using Human Event Analysis Technique (ATHEANA)

Introduction: Industrial accidents are among the major problems of today's societies. Studies on accidents indicated that the most important cause of their occurrence was the human factor. Therefore, the purpose of this study was to identify and evaluate human error in the operation of furnace using the human event analysis technique in a petrochemical industry.
 Methods: This was a qualitative and cross-sectional study which was analyzed by directly observing the activities, interviewing the analysis, and reviewing the documents and instructions, tasks and sub-tasks by Hierarchical task analysis (HTA) method, and the results were provided in HTA charts. In the next step, according to Technique for Human Error Analysis (ATHEANA) instructions, the relevant worksheet was completed.
 Results: The results indicated that coil breakage or precision instrument connections, improper bypassing of pressure in the paths to rotate the furnace to the atmosphere, or process and leakage of gas lines, flanges and valves whose probability of defect was 0.20, 0.14 and 0.13, respectively, had the highest probability of error. The probability of human error in the operation of the furnace was calculated to be 0.63.
 Conclusion: Applying corrective measures such as: selecting skilled people, holding training courses, routine monitoring of temperature, pressure measuring equipment, etc. for proper operation of the apparatus and visual monitoring of all furnace parts, including valves, are some of the things with which the likelihood of human error in the operation of the furnaces was reduced.

A Cognitive Human Error Analysis with CREAM in Control Room of Petrochemical Industry

Background: The cognitive human error analysis technique is one of the second-generation techniques used to evaluate human reliability; it has a strong, detailed theoretical background that focuses on the important cognitive features of human behavior. Objectives: The aim of this study was to assign task and jobs crisis using analysis of cognitive human error with CREAM. Finally, based on the results, the major causes of error were detected. Methods: This cross-sectional study was conducted on 53 people working in an olefin unit. It is one of the most important control rooms located in a special economic zone in Assaluyeh petrochemical industry. In this study, first a job analysis was conducted and the sub-tasks and conditions affecting the performance of the staff were determined. Then, the control mode coefficient and control mode type, as well as the possibility of total error were determined. Finally, the cognitive functions and type of cognitive error related to each sub-task were identified. Results: Amongthe six evaluated occupational tasks, the tasks performed by board-manandsite-manhadthe highest values of total human error in terms of transitory overall error coefficient (0.056 and 0.031, respectively). In addition, the following results were obtained on the basis of the extended CREAM: execution failure (31.72%), interpretation failure (29.20%), planning failure (14.63%), and observation failure (24.39%). Conclusions: Common Performance Conditions (CPCs), empowerment, and the time available for work were among the most important factors that reduced occupational performance. To optimize a communication system, it is necessary to arrange the priority of tasks, hold joint meetings, inform the staff about the termination of work permits, hold training sessions, and measure the pollutants. Keywords: Human Error, Control Room, Petrochemical Industry, CREAM

A DFM/Fuzzy/ATHEANA Human Failure Analysis of a Digital Control System for a Pressurizer

A methodology comprising Dynamic Flowgraph Methodology (DFM) and A Technique for Human Error Analysis (ATHEANA) is applied to a digital control system proposed for the pressurizer of current pressurized water reactor plants. The methodology consists of modeling this control system and its interactions with the controlled process and operator through an integrated DFM/ATHEANA approach. The results were complemented by the opinions of experts in conjunction with fuzzy theory. In terms of human reliability, DFM, along with ATHEANA, can model equipment failure modes, operator errors (omission/commission), and human factors that, combined with plant conditions, influence human performance. The results show that the methodology provides an efficient fault analysis of digital systems identifying all possible interactions among components. Through prime implicants, the methodology shows the event combinations that lead to system failure. Quantitative results obtained are in agreement with literature data, with a few percentage value discrepancies.

휴먼에러를 중심으로 한 위험요인 도출 방법론에 관한 연구

Human error is one of the major contributors to the accidents. A lot of risk assessment techniques have been developed for prevention of accidents. Nevertheless, most of them were interested in physical factors, because quantitative evaluation of human errors was difficult quantitatively. According to lack of risk assessment techniques about human errors, most of industrial risk assessment for human errors were based on data of accident analysis. In order to develop an effective countermeasure to reduce the risk caused by human errors, a systematic analysis is needed. Generally, risk assessment system is composed of 5 step(classification of work activity, identification of hazards, risk estimation, evaluation and improvement). This study aimed to develop a risk identification technique for human errors that could mainly be applied to industrial fields. In this study, Ergo-HAZOP and Comprehensive Human Error Analysis Technique were used for developing the risk identification technique. In the proposed risk identification technique, Ergo-HAZOP was used for broad-brush risk identification. More critical risks were analysed by Comprehensive Human Error Analysis Technique. In order to verify applicability, the proposed risk identification technique was applied to the work of pile head cutting. As a consequence, extensive hazards were identified and fundamental countermeasures were established. It is expected that much attention would be paid to prevent accidents by human error in industrial fields since safety personnel can easily fint out hazards of human factors if utilizing the proposed risk identification technique.

A THERP/ATHEANA Analysis of the Latent Operator Error in Leaving EFW Valves Closed in the TMI-2 Accident

This paper aims at performing a human reliability analysis using THERP (Technique for Human Error Prediction) and ATHEANA (Technique for Human Error Analysis) to develop a qualitative and quantitative analysis of the latent operator error in leaving EFW (emergency feed-water) valves closed in the TMI-2 accident. The accident analysis has revealed a series of unsafe actions that resulted in permanent loss of the unit. The integration between THERP and ATHEANA is developed in a way such as to allow a better understanding of the influence of operational context on human errors. This integration provides also, as a result, an intermediate method with the following features: (1) it allows the analysis of the action arising from the plant operational context upon the operator (as in ATHEANA), (2) it determines, as a consequence from the prior analysis, the aspects that most influence the context, and (3) it allows the change of these aspects into factors that adjust human error probabilities (as in THERP). This integration provides a more realistic and comprehensive modeling of accident sequences by considering preaccidental and postaccidental contexts, which, in turn, can contribute to more realistic PSA (Probabilistic Safety Assessment) evaluations and decision making.

해양사고조사를 위한 인적 오류 분석사례

Nationally and internationally reported statistics on marine accidents show that 80% or more of all marine accidents are caused fully or in part by human error. According to the statistics of marine accident causes from Korean Maritime Safety Tribunal(KMST), operating errors are implicated in 78.7% of all marine accidents that occurred from 2002 to 2006. In the case of the collision accidents, about 95% of all collision accidents are caused by operating errors, and those human error related collision accidents are mostly caused by failure of maintaining proper lookout and breach of the regulations for preventing collision. One way of reducing the probability of occurrence of the human error related marine accidents effectively is by investigating and understanding the role of the human elements in accident causation. In this paper, causal factors/root causes classification systems for marine accident investigation were reviewed and some typical human error analysis methods used in shipping industry were described in detail. This paper also proposed a human error analysis method that contains a cognitive process model, a human error analysis technique(Maritime HFACS) and a marine accident causal chains, and then its application to the actual marine accident was provided as a case study in order to demonstrate the framework of the method.

Human Error Analysis Technique and Its Application to Marine Accidents

The management of safety at sea is based on a set of internationally accepted regulations and codes, governing or guiding the design and operation of ships. The regulations most directly concerned with human safety and protection of the environment are, in general, agreed internationally through the International Maritime Organization(IMO). IMO has continuously dealt with safety problems and, recognized that the human element is a key factor in both safety and pollution prevention issues(IMO, 2010). This paper proposes a human error analysis methodology which is based on the human error taxonomy and theories (SHELL model, GEMS model and etc.) that were discussed in the IMO guidelines for the investigation of human factors in marine casualties and incidents. In this paper, a cognitive process model, a human error analysis technique and a marine accident causal chains focused on human factors are discussed, and towing vessel collision accidents are analyzed as a case study in order to examine the applicability of the human error analysis technique to marine accidents. Also human errors related to those towing vessel collision accidents and their underlying factors are discussed in detail.

원자력 발전소 주제어실 인터페이스 설계를 위한 인적오류 분석 기법의 보완

This study describes a modification of the technique for human error analysis in nuclear power plants (NPPs) which adopts advanced Man-Machine Interface (MMI) features based on computerized working environment, such as LCOs. Flat Panels. Large Wall Board, and computerized procedures. Firstly, the state of the art on human error analysis methods and efforts were briefly reviewed. Human error analysis method applied to NPP design has been THERP and ASEP mainly utilizing Swain`s HRA handbook, which has not been facilitated enough to put the varied characteristics of MMI into HRA process. The basic concepts on human errors and the system safety approach were revisited, and adopted the process of FMEA with the new definition of Error Segment (ESJ. A modified human error analysis process was suggested. Then, the suggested method was applied to the failure of manual pump actuation through LCD touch screen in loss of feed water event in order to verify the applicability of the proposed method in practices. The example showed that the method become more facilitated to consider the concerns of the introduction of advanced MMI devices, and to integrate human error analysis process not only into HRA/PRA but also into the MMI and interface design. Finally, the possible extensions and further efforts required to obtain the applicability of the suggested method were discussed.