Operators’ signal-detection performance in video display unit monitoring tasks of the main control room

This study evaluated the operators’ signal-detection performance in video display unit (VDU) monitoring tasks of the main control room (MCR). So far the study of the relationship between VDU design strategy and human errors has been superficial. To validate the effect of VDUs design strategies on operating errors in the MCR, this present research adopted a within subject experimental design to develop different experimental treatments based on two types of display modes included consistent mode and mixed mode. A total of 13 undergraduate and graduate students were recruited as participants in the experiment. Dependent variables included situation awareness, reaction time, error frequency, and subjective performance. Some research support was found for the representation principles. The conclusions of this study could not only be implemented by the human-system interface (HSI) designers of a MCR in the advanced nuclear power plant (NPP) but also could be generalized to the extent that other digital workstation similar to the MCR.     

Automation design in advanced control rooms of the modernized nuclear power plants

This study evaluated the effects of levels of automation (LOAs) decisions in advanced control rooms of the modernized nuclear power plants. Following advancements in design of digitalized human–system interfaces (HSIs), the roles of human operators have changed significantly. Negative performance and safety consequences may occur as a result of these changes. These problems are viewed as the out-of-the-loop (OOTL) performance problems. This study conducted an experiment to compare the effects of different LOAs under different operating procedures on operating performance. Experimental results indicated that blended decision-making (level 6 LOA) generates the lowest mental workload. Furthermore, the pattern of SA observed in this study is found better SA at intermediate LOA and poorer SA at low level of automation and full automation. Subjective rating results suggest that LOAs distribute the roles of option generation, and selection between human and/or computer servers which significantly impacts automated system performance. This study provides a direction for the HSI designers in nuclear power plants (NPPs). Additionally, based on results obtained by this study, the user interfaces of PCTRAN system and the alarm reset system should be improved to ensure safe operation of NPPs.     

数字化控制室信息显示对人因可靠性的影响

数字化技术的应用使主控室内信息显示方式发生了重大变化。通过比较分析数字化主控室与传统主控室人机界面中信息显示方面各自的特征,发现人机界面数字化后,巨量信息与有限显示的矛盾非常突出,并伴随产生任务繁重但又是必须的界面管理任务,它们对人因可靠性产生了前所未有的影响,增加了新的人因失误源,可能出现新的人误模式。提出3个新的科学概念,即信息显示率、信息提供率和数据更新率,认为研究这3个概念之间的关系和它们对操纵员认知行为的影响,是解决巨量信息与有限显示矛盾的有效途径。     

The implementation of a human factors engineering checklist for human–system interfaces upgrade in nuclear power plants

The primary purpose of this paper is to provide a human factors engineering (HFE) checklist for human–system interfaces (HSIs) upgrades in nuclear power plants (NPPs). The HFE checklist is used to review the HSIs design submittals prepared by licensees or applicants for a license or design certification of a HSI upgrade. NUREG-series regulation documents are used to develop the main frame of the initial HFE checklist. The contents of the HFE checklist are constructed by the theories and principles governing human factors. Then, verification and validation (V&V) of the HFE checklist is accomplished by validity and reliability evaluation. The results show that the HFE checklist has sufficient validity and reliability for the review of HSI upgrades in NPPs.     

Predicting work performance in nuclear power plants

Diagnosis and monitoring are the major tasks of an operator in main control room of nuclear power plants (NPPs). The operator’s mental workload influences his/her performance, and furthermore, affects the system safety and operations. This study investigated the operator’s mental workload and work performance of the NPP in Taiwan. An experiment including primary and secondary tasks was designed to simulate the reactor shutdown procedure of the fourth nuclear power plant (FNPP). The performance of the secondary tasks (error rate), subjective mental workload (NASA Task Load Index, NASA-TLX) as well as seven physiological indices were assessed and measured. The group method of data handling (GMDH) was applied to integrate these physiological indices to develop a work performance predictive model. The validity of the proposed model is very well with R² = 0.84 and its prediction capability is high (95% confidence interval). The proposed model is expected to provide control room operators a reference value of their work performance by giving physiological indices. Besides NPPs, the proposed model can be applied to many other fields, e.g. aviation, air transportation control, driving and radar vigilance, etc.     

On the operator action analysis to reduce operational risk in research reactors

Human errors during operation and the resulting increase in operational risk are major concerns for nuclear reactors, just as they are for all industries. Additionally, human reliability analysis together with probabilistic risk analysis is a key element in reducing operational risk. The purpose of this paper is to analyze human reliability using appropriate methods for the probabilistic representation and calculation of human error to be used alongside probabilistic risk analysis in order to reduce the operational risk of the reactor operation. We present a technique for human error rate prediction and standardized plant analysis risk. Human reliability methods have been utilized to quantify different categories of human errors, which have been applied extensively to nuclear power plants. The Tehran research reactor is selected here as a case study, and after consultation with reactor operators and engineers human errors have been identified and adequate performance shaping factors assigned in order to calculate accurate probabilities of human failure.     

核电站中处理人的行为问题的系统方法

引发事件的失误原因或者作为行为趋向的一部分统称为人的行为问题.总结出了核电站中处理人的行为问题的系统方法,即从问题的识别与描述、事件调研、原因分析到开发纠正行动这样一个过程.结合核电站实际,着重介绍了人误原因的识别,如根原因分析技术和起因树.     

Evaluation and comparison of alarm reset modes in advanced control room of nuclear power plants

An automation function has been widely applied in main control room of nuclear power plants (NPPs). The alarm system of fourth nuclear power plant (FNPP) in Taiwan is also going to be developed with automatic technology that is expected to support the operators’ performance and reduce the number of alarms. In this study, an experiment with a training simulator as an advanced alarm system was conducted to compare the effects of different alarm reset modes on performance and subjective ratings. The objective was to evaluate the practicability of alarm system with only auto-reset function in FNPP. Results revealed that, using the auto-reset mode, participants had lower task load index (TLX) on effort in the first test trial and was more satisfied under multi-task condition. In contrast, using manual reset mode, participants were more satisfied on alarm handling, monitoring, and decision making. In other words, both reset modes are necessary to assist the operator in different aspects, but with only single reset mode is insufficient. The reset function in advanced alarm system therefore should be very flexible.     

Development of extended speech act coding scheme to observe communication characteristics of human operators of nuclear power plants under abnormal conditions

Communication problems have long been regarded as one of the biggest causes of trouble in many workplaces. Consequently, as a part of human error analysis, extensive research has been conducted into communication. The existing research indicates that maintaining reliable communication is essential to securing the safety of a large and complex process or system. To observe the characteristics of communication, verbal protocol analysis using speech act coding schemes have been widely used in much of the related research. However, as existing speech act coding schemes do not provide a sufficient analysis information other than the distribution rate of each pattern, the development of extended communication categories is essential to overcoming the weaknesses of protocol analysis. The objective of this study is to suggest an extended speech act coding scheme and to elucidate the communication pattern characteristics of an operator’s conversation during a simulated abnormal condition in a nuclear power plant (NPP). The expected results are that conversation between operators using Multi-Way communication can increase the accuracy of information delivery and eliminate the possibility of improper operation. Therefore, communication quality control can be regarded as an important research area to minimize the occurrence of human error during communication. From this perspective, the results of this study would be a good starting point to improving the quality of communications in the workplace.     

用层次分析法分析核电站中影响人误的组织因素

应用层次分析法的基本原理,构建核电站中影响人误的组织因素AHP(层次分析法)模型,确定影响人误的组织因素的指标体系,将成对比较矩阵的特征向量作为组织因素的权重,确定了相关因子的影响力排序。研究结果显示:培训与交流反馈是影响人误的主要组织因素;强化质量监督与控制以及加强交流协作与技能培训,是减少核电站人误发生的重要举措。     

An integrated framework to the predictive error analysis in emergency situation

This paper introduces an analysis framework and procedure to predictively analyze human errors in performing emergency tasks, which are mostly composed of cognitive activities, in nuclear power plants. The framework focuses on the cognitive errors and provides a new perspective in the utilization of context factors into cognitive error prediction. The basic viewpoint on the occurrence of cognitive error taken in this paper is that the cognitive function failures occur from the mismatch between operator's cognitive capability and the requirements of a given task and situational condition. In accordance with this viewpoint, performance influencing factors that influence the occurrence of human errors are classified into three groups, i.e. Performance Assisting Factors (PAF), Task Characteristic Factors (TCF), and Situational Factors (SF). This classification helps analysts view the overall task context in an integrative way by considering the level of PAF with the requirements of TCF and SF to predict the possibility of cognitive function failures. Further, it enables analysts to draw specific error reduction strategies. The framework suggested was applied to the analysis of cognitive error potential for the bleed and feed operation of emergency tasks in nuclear power plants.     

基于信息加工模型的管制员差错分类与分析

在Wickens的人类信息加工模型的基础上,加入注意功能、情景意识、内部和外部操作成形因素,建立了管制员信息处理模型。按照该模型,空中交通管制人为差错可按照认知领域分为感知与警觉性差错、短时记忆差错、长时记忆差错、判断与计划差错、响应选择差错和响应执行差错;影响管制员操作的情境条件可分为外部操作成形因素和内部操作成形因素。对以往空管人为差错的分析表明,在信息加工层面分类的人为差错更宜于确定差错的心理致因。基于该理论模型的差错分类系统可以改进人为差错分析的有效性和一致性,从而提高差错管理的有效性。     

Errors of perception in air traffic control

Accurate and timely perception of visual and auditory information by air traffic controllers is critical to aviation safety. The aim of this research was to investigate the types of errors of perception that occur in air traffic control (ATC). The data were gathered from interviews with 28 UK area controllers and a review of 48 area and terminal control incidents involving loss of separation in the UK spanning three years. The data gave rise to a set of classifications, which form part of the technique for the retrospective analysis of human error (TRACEr). The results are discussed in terms of theory and empirical research. Key main implications for future automation are outlined, in terms of display design, automation reliability and the operation of multiple tools designed and developed separately.     

Classification of errors contributing to rail incidents and accidents: A comparison of two human error identification techniques

Identifying the errors that frequently result in the occurrence of rail incidents and accidents can lead to the development of appropriate prevention and/or mitigation strategies. Nineteen rail safety investigation reports were reviewed and two error identification tools, the Human factors analysis and classification system (HFACS) and the Technique for the retrospective and predictive analysis of cognitive errors (TRACEr-rail version), used as the means of identifying and classifying train driver errors associated with rail accidents/incidents in Australia. We aimed to identify the similarities and differences between the techniques in their capacity to identify and classify errors and also to determine how consistently the tools are applied. The HFACS analysis indicated that slips of attention (i.e. ‘skilled based errors’) were the most common ‘unsafe acts’ committed by drivers. The TRACEr-rail analysis indicated that most ‘train driving errors’ were ‘violations’ while most ‘train stopping errors’ were ‘errors of perception’. Both tools identified the underlying factors with the largest impact on driver error to be decreased alertness and incorrect driver expectations/assumptions about upcoming information. Overall, both tools proved useful in categorising driver errors from existing investigation reports, however, each tool appeared to neglect some important and different factors associated with error occurrence. Both tools were found to possess only moderate inter-rater reliability. It is thus recommended that the tools be modified, or a new tool be developed, for complete and consistent error classification.     

基于HERA-JANUS模型的空管人误认知分析

空管人误分类分析是空管人误研究的基础。为了对管制员人误进行系统的分类研究,结合空管业务知识和认知心理学理论,对欧洲航空安全局和美国联邦航空局合作开发的HERA-JANUS模型的工作原理和流程进行较详细地分析。运用该方法模型,对我国一起空管不安全事件案例进行分析后得到3个由管制员所产生的人误差错,并对这3个人误差错分别从人误类型、人误认知、相关因素3方面进行详尽的分析研究,最后得出该不安全事件的21项人误结果。结果表明,HERA-JANUS模型能较全面地从深层次分析管制员的人误,其分类形式也便于开展空管人误统计。     

Dynamic management of human error to reduce total risk

Safety management in companies at the limit of risk criteria must be implemented in order to survive in the very aggressive and competitive environment of modern society. It implies that the risk in process industries is crossing the limit of safe practices. Most major accidents consist of human errors and mechanical component failures, and cannot be explained by a stochastic coincidence of independent events. This work focuses on the coincidence of human error and mechanical failure to introduce a concept of dynamic management of human error. By the dynamic management of human error during a short period, when a mechanical component is temporarily unavailable during periodic testing or maintenance, the probability of a major accident may be reduced significantly without additional investment on improving safety. For the periodically-tested standby component, the majority of total average unavailability of the component may be recognized by operators or workers as well as maintenance mechanics. During this short period, an appropriate dynamic management of human error for improving human performance temporarily may be very effective in reducing total risk in industries. The dynamic management of human error may be a useful method to prevent loss effectively in the process industries     

Consequence risk analysis using operating procedure event trees and dynamic simulation

Faults due to human errors cost the petrochemical industry billions of dollars every year and can have adverse environmental consequences. Unquantified human error probabilities exist during process state transitions performed each day by process operators using standard operating procedures. Managing the risks associated with operating procedures is an essential part of managing the overall safety risk. Additional operator training and safety education cannot eliminate all such faults due to human errors; therefore, we propose an operating procedure event tree (OPET) like analysis with branches and events specifically designed to perform risk analysis on operating procedures. The OPET method adapts event trees to analyze the risk due to human error while performing operating procedures. We consider human error scenarios during the procedure and determine the likely consequences by applying dynamic simulation. The modified event tree provides an estimate of the error frequencies.Operating procedure steps were developed, and potential operator faults were determined for two typical equipment switching procedures found in chemical plant operations. Then, dynamic simulation using Aspen HYSYS software was applied to determine the overpressure related consequences of each fault. Finally, the error frequencies resulting from those scenarios were analyzed using operating procedure event trees. We found that a typical ethylene plant gas header would overpressure with 0.6% frequency per manual dryer switch. Since dryer switches occur from every few days up to once per shift, these results suggest that dryer switching should be automated to ensure safe and environmentally friendly operation. Process dryer switching performed manually by operators opening and closing gate valves can be automated with control valves and a distributed control system. A sample distillation column was found to overpressure with 0.85% frequency per manual reflux pump switch.     

基于人的认知可靠性(HCR)模型的人因操作失误研究

以人的认知可靠性(HCR)模型为指导,选择包含技能型、规则型和知识型3种认知类型,结合大连化工集团公司影响运行安全的17个异常事件,对54名操纵员的时间响应状况和允许操作时间进行录像、记录与分析;依据IAEA提供的指标[1],找出操纵员在生产过程中可能出现的操作失误类别及其可能造成的危害;基于3参数威布尔模型推导出操纵员操作响应失误概率模型,并从人机工程学角度提出了具体预防事故的安全对策措施。结果表明,基于HCR模型的大化集团公司操纵员的人因操作失误模型实用、有效,为实现操作者与机器系统相协调的目标、正确评估操作着实时操作的响应时间提供了重要参考依据。     

核电站FDA安全管理信息流系统模型的构建研究

为了从安全信息的角度完善核电站的事故致因机理，并在实践中加强核电站的安全管理，首先以安全信息为视角，以系统安全行为链为主线，建立核电站FDA安全管理信息流系统模型，该模型由运行操作人员、核电站企业、国家核安全局3条子链和1条必要安全信息主链构成；然后结合模型和核电站具体工作流程，分析得到3个子事故域和1个总事故域，并归纳出核电站安全运行各阶段所需的必要安全信息；最后结合事故域，分析模型在核电站安全管理中的实际应用价值。