Human error risk analysis in offshore emergencies

Human factors play an important role in the completion of emergency procedures. Human factors analysis is rooted in the concept that humans make errors, and the frequency and consequences of these errors are related to work environment, work culture, and procedures. This can be accounted for in the design of equipment, structures, processes, and procedures. As stress increases, the likelihood of human error also increases. Offshore installations are among the harshest and most stressful work environments in the world. The consequences of human error in an offshore emergency can be severe.A method has been developed to evaluate the risk of human error during offshore emergency musters. Obtaining empirical data was a difficult process, and often little information could be drawn from it. This was especially an issue in determining the consequences of failure to complete muster steps. Based on consequences from past incidents in the offshore industry and probabilities of human error, the level of risk and its tolerability are determined. Using the ARAMIS (accidental risk assessment methodology for industries) approach to safety barrier analysis, a protocol for choosing and evaluating safety measures to reduce and re-assess the risk was developed. The method is assessed using a case study, the Ocean Odyssey incident, to determine its effectiveness. The results of the methodology agree with the analysis of survivor experiences of the Ocean Odyssey incident.     

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CREAM和贝叶斯网络的航空维修人为差错概率预测

航空维修差错不仅严重威胁着飞行安全,同时也会增加航空公司的维修成本。针对航空维修人员发生差错成因的复杂性以及历史事故数据缺乏的情况下,将人因可靠性与失误分析方法（CREAM）和贝叶斯网络（BN）相结合,提出一种改进的维修差错分析模型。根据维修任务构建相应的贝叶斯网络模型,为各子节点设置条件概率表（CPT）;基于维修基地的实际维修环境,对行为形成因子（PSFs）进行评估,得到共同绩效条件（CPCs）的水平;利用各CPC因子下各个行为功能失效模式的权重因子,对各认知活动进行失效概率的修正;将修正概率作为贝叶斯网络根节点的输入,利用推理机制,得到差错发生概率。通过案例分析和计算,验证了所述方法的可行性和有效性。     

基于CREAM和贝叶斯网络的空管人误概率预测方法

针对研究管制人因可靠性时存在的模糊性和片面性问题，采用认知可靠性与失误分析方法（CREAM）中的扩展预测法，计算10项管制通用任务的人误概率；在此基础上，以管制行为形成因子作为根节点构建贝叶斯网络，建立其与情景控制模式的不确定关系模型，对管制员在多任务中的人误概率进行预测。研究结果表明:在由相同评判者给出行为形成因子影响效应的前提下，由CREAM扩展预测法和构建贝叶斯网络的方法预测得到的多数任务的人误概率差异较大，从方法的客观性、合理性和适用性角度分析，贝叶斯网络在研究该问题时更具优势。     

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。     

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.     

海洋钻井平台事故致因分析与评价指标研究

该文在广泛调研国内外已发生的海洋平台事故基础上,从人因失误、工艺设备、物料危险、管理缺陷和危险环境五个方面系统分析事故致因因素,提出海洋钻井平台事故致因评价框架,提出5个一级评价指标和24个二级评价指标,根据层次分析法,计算确定各指标的标准权重值.最后针对某在役海洋钻井平台,开展实例研究.为实际评价海洋钻井平台事故风险提供一种新方法,具有一定的实际应用价值.     

基于全生命周期的海洋油气项目集风险管理

为了强化海洋油气项目集的风险管理,以海洋油气田固定区块开发为范围,基于甲方油气田单位和乙方服务单位立场,对项目集进行全生命周期的风险管理;将海洋油气项目集生命周期划分为6个阶段;提出了滚动风险管理模式,给出各阶段风险分解结构和风险应对策略;以时间、成本、质量为控制要素,建立项目整体风险动态评估方法。研究结果表明:通过生命周期6个阶段和整体2级动态迭代风险控制,能更早发现项目集各级过程风险,有助于避免或降低风险事故带来的损失,更有效地保障项目集收益和组织战略实现,可为我国海上油气田开发风险管理提供新参考。     

Issues of the Human Reliability Analysis in the Context of Probabilistic Safety Studies

This article addresses methodological issues of the human reliability analysis (HRA) in the context of probabilistic safety studies. Several conventional HRA techniques, more often used for the evaluation of the human error probabilities (HEPs), have been classified. A taxonomy of human actions, failure events, and related factors is outlined in order to distinguish action phases, human behavior types and incorrect outputs (errors of omission or commission), error types (slips, lapses, and mistakes), and performance-shaping factors (PSFs) influencing the human performance. A tree is proposed to facilitate the selection of a specific method for the evaluation of human reliability with regard to attributes of the situation analyzed. A software system based on the expert system technology to facilitate and document PSA and HRA is outlined. At the end of the article some research challenges in the domain are discussed.     

复杂工业系统中班组人因失误分析

在复杂工业系统中 ,人因可靠性分析 (HRA)是预防和减少人因失误的有效方法。人在复杂工业系统中的生产活动 ,往往是由组织中班组成员集体完成的 ,完整的HRA必须充分考虑班组人误的产生。班组人误的产生有其自身的规律 ,如何合理地定义人员行为形成因子 (PSFs)是班组人因失误分析的难点 ,也是班组人因失误分析的重要手段 ,被广泛应用在核电厂 ,航空和造船工业领域的事故分析中。笔者详细分析和探讨了班组人因失误的定义、产生过程及相关的人的行为形成因子 ,以期能使大规模工业系统中的人因失误分析更加合理和完善。     

户外端子箱操作人因可靠性及其风险评价*

为正确评价人为因素对户外端子箱失效的影响,利用CREAM(Cognitive Reliability and Error Analysis Method)模型的共同绩效条件分析端子箱操作过程中人的行为机理以及行为可靠性因素;应用SLIM(Success Likelihood Index Method)模型计算人为失误概率,并采用比例故障模型计算户外端子箱自身的故障率;以某断路器端子箱为例进行验证。结果表明:研究案例的人为失误概率为1.56%,设备故障率为0.84%,系统的风险值为10.7%,系统的风险等级为3;从概率的角度说明事故发生原因中人为因素的影响更大。因此,从行为可靠性影响因素层面对人为失误概率进行调控,可使户外端子箱操作人因可靠性得到提高,系统的风险等级随之降低。     

Actual safety performance of the Malaysian offshore oil platforms: Correlations between the leading and lagging indicators

IntroductionThis study establishes the correlations between performance of a set of key safety factors and the actual lagging performance of oil platforms in Malaysia, hence the relevance of the key safety factors in evaluating and predicting the safety performance of oil and gas platforms. The key factors are crucial components of a safety performance evaluation framework and each key safety factor corresponds to a list of underlying safety indicators.MethodIn this study, participating industrial practitioners rated the compliance status of each indicator using a numbering system adapted from the traffic light system, based on the actual performance of 10 oil platforms in Malaysia. Safety scores of the platforms were calculated based on the ratings and compared with the actual lagging performance of the platforms. Safety scores of two platforms were compared with the facility status reports' findings of the respective platforms.ResultsThe platforms studied generally had good performance. Total recordable incident rates of the platforms were found to show significant negative correlations with management and work engagement on safety, compliance score for number of incident and near misses, personal safety, and management of change. Lost time injury rates, however, correlated negatively with hazard identification and risk assessment. The safety scores generally agreed with findings of the facility status reports with substandard process containment found as a contributor of hydrocarbon leaks.ConclusionsThis study proves the criterion validity of the safety performance evaluation framework and demonstrates its usability for benchmarking and continuous improvement of safety practices on the Malaysian offshore oil and gas platforms.Practical applicationsThis study reveals the applicability of the framework and the potential of extending safety reporting beyond the few conventional lagging safety performance indicators used. The study also highlights the synergy between correlating safety factors to streamline safety management on offshore platforms.     

考虑人因可靠性的安全仪表功能SIL验证方法研究

油气站场一般设置有紧急停车系统（ESD）等存在操作员介入的非常规安全仪表功能（SIF），为解决已有的安全完整性等级（SIL）评估方法不能针对此类SIF进行功能安全评价的情况。对存在操作员介入的非常规SIF进行研究，将其中的人为因素细分为观察、决策和执行3个阶段；根据各类人因可靠性分析方法优缺点，筛选CREAM和HCR方法分别分析紧急情景环境和应急响应时间对非常规SIF人因失效概率的影响，建立考虑人因可靠性的SIL验证模型；基于此模型选取某输油站典型SIF开展SIL评估，分析人因失效对SIF整体可靠性的影响水平，并提出改善措施。结果表明:将操作员应急响应过程中的人因失效概率引入传统的SIL验证模型中，可实现对非常规SIF的功能安全评价；人因失效对非常规SIF具有显著影响，筛选的人因可靠性模型可准确计算人因失效概率。     

Shift schedules on North Sea oil/gas installations: A systematic review of their impact on performance,safety and health

Continuous production processes on North Sea installations necessitate extended work schedules; 2-week offshore tours (alternating with shore breaks), 12 h shifts and rapid day/night shift changes are inherent features of offshore work. These intensive rosters, worked in a demanding physical and psychosocial environment, are potential sources of fatigue and impaired performance among offshore personnel. This article focuses on offshore working time arrangements, and presents a systematic review of studies which examine offshore day/night shift patterns in relation to operational safety and individual health risks. Of the 53 studies retrieved, 24 met the review criteria.Field study findings are generally consistent in showing that sleep, alertness and performance are relatively stable across day-shift tours; initial night shifts are adversely affected by circadian disruption, but full physiological and psychological adaptation occurs within 5–6 days; re-adaptation to day shifts is slower, and varies widely across individuals; the offshore environment is conducive to night-shift adaptation, but interventions to facilitate re-adaptation have proved only modestly effective. Analyses of survey data and accident/sickness records identify offshore night work as a risk factor for impaired sleep, health problems, and injuries, but little is known about the long-term health effects of different offshore shift rotations.In conclusion, research methodology and findings, and working time issues of current concern to the offshore oil/gas industry, are discussed. Aspects of offshore work schedules that have been not been widely studied (e.g. overtime, irregular work patterns) are also highlighted, and research areas that would merit further attention are noted.     

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。     

行为形成因子与人为差错模式的定性关联分析

为揭示人为差错的发生规律以便有效管理人为差错,研究行为形成因子与人为差错模式间的对应关系。将行为形成因子作为情景环境的表征,在SRK(skill,rule,knowledge)模型的基础上,将认知功能的效能分为3种指标:全面性、准确性和效率,将认知功能与效能指标相结合得到人为差错模式的分类。在此基础上,根据经验详细分析行为形成因子对认知功能3种效能指标的影响,得到行为形成因子与人为差错模式的关联关系表格。该关联关系是定性的,包含密切关联、重要关联、一般关联和没有关联4种关联程度,不但可以用于人为差错事件的调查,而且可以用于人为差错模式的预测。     

A methodology to model causal relationships on offshore safety assessment focusing on human and organizational factors

INTRODUCTION: Focusing on people and organizations, this paper aims to contribute to offshore safety assessment by proposing a methodology to model causal relationships. METHOD: The methodology is proposed in a general sense that it will be capable of accommodating modeling of multiple risk factors considered in offshore operations and will have the ability to deal with different types of data that may come from different resources. Reason's "Swiss cheese" model is used to form a generic offshore safety assessment framework, and Bayesian Network (BN) is tailored to fit into the framework to construct a causal relationship model. The proposed framework uses a five-level-structure model to address latent failures within the causal sequence of events. The five levels include Root causes level, Trigger events level, Incidents level, Accidents level, and Consequences level. To analyze and model a specified offshore installation safety, a BN model was established following the guideline of the proposed five-level framework. A range of events was specified, and the related prior and conditional probabilities regarding the BN model were assigned based on the inherent characteristics of each event. RESULTS: This paper shows that Reason's "Swiss cheese" model and BN can be jointly used in offshore safety assessment. On the one hand, the five-level conceptual model is enhanced by BNs that are capable of providing graphical demonstration of inter-relationships as well as calculating numerical values of occurrence likelihood for each failure event. Bayesian inference mechanism also makes it possible to monitor how a safety situation changes when information flow travel forwards and backwards within the networks. On the other hand, BN modeling relies heavily on experts' personal experiences and is therefore highly domain specific. IMPACT ON INDUSTRY: "Swiss cheese" model is such a theoretic framework that it is based on solid behavioral theory and therefore can be used to provide industry with a roadmap for BN modeling and implications. A case study of the collision risk between a Floating Production, Storage and Offloading (FPSO) unit and authorized vessels caused by human and organizational factors (HOFs) during operations is used to illustrate an industrial application of the proposed methodology.     

Safety and human factors considerations in control rooms of oil and gas pipeline systems: conceptual issues and practical observations.

All oil and gas pipeline systems are run by human operators (called controllers) who use computer-based workstations in control rooms to "control" pipelines. Several human factor elements could contribute to the lack of controller success in preventing or mitigating pipeline accidents/incidents. These elements exist in both the work environment and also in the computer system design/operation (such as data presentation and alarm configuration). Some work environment examples include shift hours, shift length, circadian rhythms, shift change-over processes, fatigue countermeasures, ergonomics factors, workplace distractions, and physical interaction with control system computers. The major objective of this paper is to demonstrate the critical effects of human and organizational factors and also to highlight the role of their interactions with automation (and automated devices) in the safe operation of complex, large-scale pipeline systems. A case study to demonstrate the critical role of human organizational factors in the control room of an oil and gas pipeline system is also presented.     

An Overview of the Nature of Hydrocarbon Jet Fire Hazards in the Oil and Gas Industry and a Simplified Approach to Assessing the Hazards

High pressure jet fires pose a serious hazard to offshore installations operated by the oil and gas industry as demonstrated by the Piper Alpha incident. Following the Piper Alpha incident a major initiative by the offshore oil and gas industry operators led to the production of Interim Guidance Notes which provided guidance to operators on how to assess jet fire hazards. However, many areas of uncertainty were identified where no data was available. Areas of particular concern identified in the Interim Guidance Notes were two-phase jet fires, the effect of confinement on jet fires and their behaviour with water deluge. Since that time a considerable body of experimental research has been undertaken. Based on this recent data, this paper reassesses jet fire hazards in an offshore environment and provides updated guidance on the hazards they pose, including tabulated data and simple calculation techniques for predicting jet fire hazards.