Determination of human error probabilities in maintenance procedures of a pump

The “human factor” constitutes an important role in the prediction of safe operation of a facility. Hence, information about human capacities and behaviours should be applied methodically to increase the safety of a systematic process. This paper provides an analysis of human factors in pre- and post-maintenance operations. For possible failure scenarios, this paper considers the procedures for removing process equipment from service (pre-maintenance) and returning the component to service (post-maintenance). In this study, a pump is used as the test example. For each scenario, the human error probability (HEP) is calculated for each activity, using the Human Error Assessment and Reduction Technique (HEART) which is commonly implemented technique in industry, can also be applied in the analyses of safety cases. HEART is a reliable technique for comparing HEP and its approach is based on the degree of error recovery. Consequences are also assessed for each activity in this methodology. The final value of risk for each activity is assigned by combining error likelihood and related consequences. When the calculated risk is beyond acceptable levels, risk management strategies are provided to increase the safety of the maintenance procedures. The most probable human errors for a considered case study are related to the activities of “draining lines” and “open valves”. These two activities have high HEPs, which are 9.57E−01 and 9.62E−01, respectively.     

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.     

Occupational Cognitive Failures and Safety Performance in the Workplace

Introduction. The majority of industrial accidents occur because of human errors. Human error has different causes, however, in all cases cognitive abilities and limitations of human play an important role. Occupational cognitive failures are cognitively-based human errors that occur at work. The aim of this study was to examine the relationship between occupational cognitive failures and safety consequences. Method. Personnel of a large industrial company in Iran filled out an occupational cognitive failure questionnaire (OCFQ) and answered questions on accidents. Univariate and multiple logistic regression analysis were used to determine the relationship between cognitive failures and safety consequences. Results. According to developed regression models, personnel with a high rate of cognitive failure, in comparison to low rate, have a high risk of minor injury involvement (OR 5.1, 95% CI [2.62, 10.3]); similar results were for major injury and near miss. Discussion. The results of this study revealed usefulness of the OCFQ as a tool of predicting safety-related consequences and planning preventive actions.     

A framework for human error risk analysis of coal mine emergency evacuation in China

Evacuation from underground coal mine in emergency as soon as possible makes the difference between life and death. Human factors have an important impact on a successful evacuation, but literature review shows that there is a lack of consideration of human error risk during coal mine emergency evacuation in China. To address the above problems, in this paper, we established a framework for human error risk analysis of coal mine emergency evacuation, consisting of scenario and task analysis, risk assessment and risk reduction. A general evacuation procedure which is applicable for different causes is detailed through the scenario and task analysis. A new method based on expert judgment, named OGI-Model, is proposed to evaluate the reliability of human safety barrier. In this new approach, human safety barrier is divided into three sub-barriers, i.e., organization safety sub-barrier (OSSB), group safety sub-barrier (GSSB), and individual safety sub-barrier (ISSB). Each sub-barrier consists of a series of concrete measures against specific evacuation actions. An example is provided in this paper to demonstrate the use of this framework and its effectiveness.     

海洋石油轮班作业风险定量分析方法研究

长期以来,海洋石油领域风险研究主要集中在对设施的潜在失效概率和后果研究方面,而对于人员可靠性及风险管理方面的研究较弱。然而,据统计资料显示,海上设施在其生命周期内的设计、建造和生产作业等各个阶段中发生的事故大多与人为错误和组织错误（HOE）有关联。在海洋工程领域,开展人员可靠性分析（HRA）的研究工作具有重要意义。根据海上作业的特殊性及轮班制度的特点,推导出轮班风险的定量分析公式,据此计算出每个工作日轮班风险的相对大小,然后结合我国海上作业的实际情况,对影响轮班风险的可变因素进行了敏感性分析,为风险控制与管理提供参考。     

基于人因失误分析的医院电气安全管理研究

医院是重点用电单位,用电的安全性和供电可靠性都比较高,但因不可抗力、供电系统故障、医院管理问题、人为失误等方面的原因,仍存在发生各类电气突发事件的风险。其中,由人的误操作或不安全行为因素而诱发的电气方面的突发事件已成为医院非医疗事故的主要原因。文章针对医院电气安全操作方面的人因失误,从个人和组织两个角度进行了失误原因的分析,认为人的失误既受个体因素的影响,也受环境、制度和管理水平的影响。在此基础上,提出完善相关规章制度建设、加强教育与培训等,从组织制度建设、人员技术素质提高等方面,提出预防与减少人因失误的措施与方法,提高供配电质量,为医院医疗工作提供有效的电气安全后勤保障。     

The criminalization of human error in aviation and healthcare: A review

This review explores the social causes and psychological and organizational consequences of the criminalization of human error in aviation and healthcare. Increasing prevalence of criminal prosecution is seen as a threat to the health and safety of employees and entire safety–critical systems in many industries, but initiatives to counter or mitigate the trend are local and haphazard. Social causes such as a greater societal risk consciousness and intolerance of failure are examined, as well as organizational consequences for disclosure and incident reporting. Psychological consequences of the criminalization of human error are evaluated in terms of employee ill-health, an area that is under-investigated. The criminalization of professional mistakes seems to be an increasingly prevalent phenomenon at the intersection of safety work, sociology, criminology and legal as well as social justice. This paper reviews possible research directions into the criminalization of professional mistake in aviation and healthcare, in the hope of stimulating debate and eventually legitimating it as a topic of study in its own right.     

考虑组织因素的液化天然气泄漏安全评价方法

为考虑组织因素对于人因失误发生的根本性影响,提出一种以贝叶斯网络(BN)为工具的人因风险分析方法,并用于液化天然气泄漏的安全评价。先将认知可靠性与失误分析方法(CREAM)的共同绩效条件(CPC)分成3层,即组织层、技术系统层和个人层。以BN为工具,利用其因果推理和诊断推理的功能,进行人因失误预测和追溯的双向分析。将考虑组织因素的人员操作失误概率引入浮式液化天然气船(FLNGV)装卸过程LNG泄漏的BN中,进行LNG泄漏的安全评价以及事故原因的重要度分析。结果表明,"执行"失误是LNG泄漏最主要的事故原因,而个人层的CPC会对执行失误产生较大的影响。     

Risk assessment tools incorporating human error probabilities in the Japanese small-sized establishment

Although it has been estimated that as many as 80% of all occupational accidents have human errors as a cause, no risk assessment tools incorporating human-related elements have been developed for small companies. Human error probability (HEP) and human error analysis (HEA) have been used for large-scale, safety-critical industries for last three decades, but these tools are not suitable for smaller, more general industries that comprise the majority of accident settings.Here, we describe and verify a risk assessment tool that includes human-related elements for small companies. The tool expands on traditional risk assessment methods, such as matrix, risk graph and numerical scoring method, by adding human-related elements. The tool is easy-to-use in occupational environments, and includes assessments of human behavior and potentially outdated machinery at work place.     

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.     

Conceptual compression discussion on a multi-linear (FTA) and systematic (FRAM) method in an offshore operation’s accident modeling

Risk assessment can be classified into two broad categories: traditional and modern. This paper is aimed at contrasting the functional resonance analysis method (FRAM) as a modern approach with the fault tree analysis (FTA) as a traditional method, regarding assessing the risks of a complex system. Applied methodology by which the risk assessment is carried out, is presented in each approach. Also, FRAM network is executed with regard to nonlinear interaction of human and organizational levels to assess the safety of technological systems. The methodology is implemented for lifting structures deep offshore. The main finding of this paper is that the combined application of FTA and FRAM during risk assessment, could provide complementary perspectives and may contribute to a more comprehensive understanding of an incident. Finally, it is shown that coupling a FRAM network with a suitable quantitative method will result in a plausible outcome for a predefined accident scenario.     

事故前人因失误研究

在安全评价中，人因失误特别是事故后人因失误越来越受到重视；但相对而言，事故前人因失误没有引起足够的重视。本通过对大量核电厂安全分析报告和运行事件报告的考察，系统地阐述了事故前人因失误对系统安全的显影响，并在此基础上，归纳出在核电站开展事故前人因(失误)分析的程序。该程序主要包括系统熟悉，定性分析，筛选，定量计算，与故障树的集成，敏感性分析与不确定性分析，形成分析档等几个步骤。     

Offshore safety case approach and formal safety assessment of ships

PROBLEM: Tragic marine and offshore accidents have caused serious consequences including loss of lives, loss of property, and damage of the environment. METHOD: A proactive, risk-based "goal setting" regime is introduced to the marine and offshore industries to increase the level of safety. DISCUSSION: To maximize marine and offshore safety, risks need to be modeled and safety-based decisions need to be made in a logical and confident way. Risk modeling and decision-making tools need to be developed and applied in a practical environment. SUMMARY: This paper describes both the offshore safety case approach and formal safety assessment of ships in detail with particular reference to the design aspects. The current practices and the latest development in safety assessment in both the marine and offshore industries are described. The relationship between the offshore safety case approach and formal ship safety assessment is described and discussed. Three examples are used to demonstrate both the offshore safety case approach and formal ship safety assessment. The study of risk criteria in marine and offshore safety assessment is carried out. The recommendations on further work required are given. IMPACT ON INDUSTRY: This paper gives safety engineers in the marine and offshore industries an overview of the offshore safety case approach and formal ship safety assessment. The significance of moving toward a risk-based "goal setting" regime is given.     

Determination of human error probabilities for offshore platform musters

The focus of this work is on prediction of human error probabilities during the process of emergency musters on offshore oil and gas production platforms. Due to a lack of human error databases, and in particular human error data for offshore platform musters, an expert judgment technique, the Success Likelihood Index Methodology (SLIM), was adopted as a vehicle to predict human error probabilities. Three muster scenarios of varying severity (man overboard, gas release, and fire and explosion) were studied in detail. A panel of 24 judges active in the offshore oil and gas industry provided data for both the weighting and rating of six performance shaping factors. These data were subsequently processed by means of SLIM to calculate the probability of success for 18 muster actions ranging from point of muster initiator to the final actions in the temporary safe refuge (TSR). The six performance shaping factors considered in this work were stress, complexity, training, experience, event factors and atmospheric factors.     

A dynamic Bayesian networks modeling of human factors on offshore blowouts

An application of dynamic Bayesian networks for quantitative risk assessment of human factors on offshore blowouts is presented. Human error is described using human factor barrier failure (HFBF), which consists of three categories of factors, including individual factor barrier failure (IFBF), organizational factor barrier failure (OFBF) and group factor barrier failure (GFBF). The structure of human factors is illustrated using pseudo-fault tree, which is defined by incorporating the intermediate options into fault tree in order to eliminate the binary restriction. A methodology of translating pseudo-fault tree into Bayesian networks and dynamic Bayesian networks taking repair into consideration is proposed and the propagation is performed. The results show that the human factor barrier failure probability only increases within the first two weeks and rapidly reaches a stable level when the repair is considered, whereas it increases continuously when the repair action is not considered. The results of mutual information show that the important degree sequences for the three categories of human factors on HFBF are: GFBF, OFBF and IFBF. In addition, each individual human factor contributes different to the HFBF, those which contribute much should given more attention in order to improve the human reliability and prevent the potential accident occurring.     

Allocation of performance shaping factors in the risk assessment of an offshore installation

Offshore oil production is one of the most important human productive activities. There are many risks associated with the process of constructing a subsea well, pumping oil to the platform, and transporting it to refineries via underwater pipes or oil tankers. All actions performed by workers in those operations are influenced by specific working conditions, involving the use of complex systems. Contextual factors such as high noise, low and high temperatures and hazardous chemicals are considered to be contributors to unsafe human actions in accident analysis and also give a basis for assessing human factors in safety analysis. Some failure modes are particularly dangerous and can result in severe accidents and damage to humans, the environment and material assets. Fires and explosions on oil rigs are some of the most devastating types of offshore accidents and can result in long-term consequences. The most typical root causes related to accidents include equipment failure, human error, environmental factors, work organization, training and, communication, among others. The principal objective of this study is to propose a methodological framework to identify the factors that affect the performance of operators of an offshore unit for oil processing and treatment. In this phase, an ergonomics approach based on operators' work analysis is used as a supporting tool. After identification of factors that affect the performance of operators, a decision-making model based on AHP (analytic hierarchy process) is applied to rank and weight the principal performance shaping factors (PSFs) that influence safe operations. The next step involves the use of the SHELLO model to group the main PSFs in elements named software, hardware, environment, liveware and organization. In the last phase, a relevant accident that occurred aboard a floating production storage and offloading (FPSO) vessel is analyzed. The allocation process of the factors that affect the operator's performance in risk assessment was developed through fuzzy logic and the ISO 17776 standard.     

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。     

The paradoxes of almost totally safe transportation systems

Safety remains driven by a simple principle: complete elimination of technical breakdowns and human errors. This article tries to put this common sense approach back into perspective in the case of ultra-safe systems, where the safety record reaches the mythical barrier of one disastrous accident per 10 million events (10⁻⁷). Three messages are delivered: (1) the solutions aimed at improving safety depend on the global safety level of the system. When safety improves, the solutions used to improve the safety record should not be further optimised; they must continue to be implemented at present level (to maintain the safety health obtained), and supplemented further by new solutions (addition rather than optimisation rationale); (2) the maintenance and linear optimisation of solutions having dwindling effectiveness can result in a series of paradoxes eventually replacing the system at risk and jeopardising the safety record obtained in the first place; and (3) after quickly reviewing ambiguities in the definition of human error and the development of research in this area, this article shows, through recent industrial examples and surveys, that errors play an essential role in the acquisition and effectiveness of safety, at individual as well as collective levels. A truly ecological theory of human error is developed. Theories of error highlight the negative effects of an over-extensive linear extrapolation of protection measures. Similarly, it is argued that accepting the limitation of technical systems performance through the presence of a minimum breakdown and incident ‘noise’ could enhance safety by limiting the risks accepted. New research opportunities are outlined at the end of this paper, notably in the framework of systems now safe or ultra-safe.