The research on extracting the information of human errors in the main control room of nuclear power plants by using Performance Evaluation Matrix

Digitalized nuclear instruments and control systems have been the main stream design for the main control room (MCR) of advanced nuclear power plants (NPPs) nowadays. Digitalization of human–system interface (HSI) could improve human performance and, on the other hand, could reduce operators’ situation awareness as well. It might cause that humans make wrong decision during an emergency unintentionally. Besides, digital HSI relies on computers to integrate system information automatically instead of human operation. It has changed the operator’s role from mainly relating operational activity to mainly relating monitoring. However, if the operators omit or misjudge the information on the video display units and wide display panel, the error of omission and error of commission may occur. This study applies Content Category Analysis (CCA) and Performance Evaluation Matrix (PEM) methods to explore the potential problems in the MCR of advanced NPPs which are caused by human errors. The results show that the potential problems that would probably contribute to the human performance of MCR in the advanced NPPs are multiple accidents, pressure level, number of operators, and other factors such as working environmental. The conclusions of this research may be considered to avoid and prevent human errors in the human factor related researches especially in the nuclear safety field.     

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.     

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.     

Airport privatisation and safety: Does ownership type affect safety?

In the summer of 2004, the Dutch cabinet decided on the privatisation of the largest airport in the Netherlands—Amsterdam Airport Schiphol (AAS). Privatisation processes have generated policy questions which have focused on assuring that public values such as safety at airports remains at levels that are considered sufficient after privatisation takes place.In this article, an attempt is made to assess the effects of the proposed privatisation on the management of safety on and around the airport. As little empirical evidence exists about the potential effects of privatisation of airport operators on the safety of air transportation, the research used a ‘worst-case scenario analysis’ to assess potential effects of a (partial) privatisation of the airport operator. Based upon a detailed investigation of a number of activities performed by the airport operator and a comparative analysis of safety regulatory systems of two other European (partly) privatised airports, we conclude that the level of safety at the airport is not directly affected as a result of the (partial) privatisation of the airport operator, but that compared to the situation in which the airport operator remains a public entity, the safety regulatory system as a whole has become less robust.     

The influence of individual differences on organizational safety attitudes

Workplace accidents cost organizations and the economy billions of dollars annually, disabling and injuring millions of employees. Employee attitudes toward safety have been shown to relate to safe workplace behavior. In an effort to determine what contributes to stronger employee attitudes toward safety, we examined the relationships between safety attitudes and a wide array of individual differences reflecting preferences and tendencies toward risk and control. Using a sample of 190 engineering and occupational safety students from two universities, we found that agreeableness, conscientiousness, prevention regulatory focus, and fatalism related significantly to all six safety attitudes examined. Regression analyses demonstrated that agreeableness, prevention focus, and fatalism significantly related to safety attitudes when controlling for the other individual differences. This study illustrates the utility of examining individual differences when predicting safety-related attitudes.     

基于视线追踪技术的工艺操作人员人为失误识别研究

为了对生产加工过程中工艺操作人员的不安全行为进行有效监控，及时避免因操作失误带来的工艺安全事故，开展基于视线追踪技术的工艺操作人员人为失误识别研究。通过设计眼动实验方案，利用视线追踪技术采集操作者在工艺流程控制过程中各类失误模式的眼动数据,并对采集的数据进行统计，提取失误行为的眼动特征，并建立人为失误智能识别方法，利用距离函数聚类实现现场操作人员失误状态的准确识别。研究结果表明:以被试样本在不同区域的视线停留时间百分比作为特征参数，并运用欧氏距离函数分类法判别人员操作状态，对操作人员的不安全行为能够准确识别。     

高处坠落事故的人因失误与干预策略研究

为系统分析导致高处坠落人因事故的产生机理,通过统计152起建筑工程高处坠落事故的调查与分析报告,从组织影响、安全监管、不安全行为前提条件和不安全行为等4个层次,辨识影响高处坠落事故的人为失误因素,修订人为因素分析与分类系统框架（HFACS）。设计高处坠落人因失误调查问卷,开展一线高处作业人员问卷调查,建立高处坠落人因失误结构方程模型,对导致高处坠落事故的人为失误因素进行路径分析。结果表明:各潜在因素间均呈正相关,且高处坠落人因失误事故的关键路径为资源管理不到位→安全监督培训不充分→班组管理不良→操作违规。综合各因素间相关性,提出了针对性的预防高处坠落事故的人因干预策略。     

Mental models of safety: do managers and employees see eye to eye?

PROBLEM: Disagreements between managers and employees about the causes of accidents and unsafe work behaviors can lead to serious workplace conflicts and distract organizations from the important work of establishing positive safety climate and reducing the incidence of accidents. METHOD AND RESULTS: In this study, the authors examine a model for predicting safe work behaviors and establish the model's consistency across managers and employees in a steel plant setting. Using the model previously described by Brown, Willis, and Prussia (2000), the authors found that when variables influencing safety are considered within a framework of safe work behaviors, managers and employees share a similar mental model. The study then contrasts employees' and managers' specific attributional perceptions. Findings from these more fine-grained analyses suggest the two groups differ in several respects about individual constructs. Most notable were contrasts in attributions based on their perceptions of safety climate. When perceived climate is poor, managers believe employees are responsible and employees believe managers are responsible for workplace safety. However, as perceived safety climate improves, managers and employees converge in their perceptions of who is responsible for safety. IMPACT ON INDUSTRY: It can be concluded from this study that in a highly interdependent work environment, such as a steel mill, where high system reliability is essential and members possess substantial experience working together, managers and employees will share general mental models about the factors that contribute to unsafe behaviors, and, ultimately, to workplace accidents. It is possible that organizations not as tightly coupled as steel mills can use such organizations as benchmarks, seeking ways to create a shared understanding of factors that contribute to a safe work environment. Part of this improvement effort should focus on advancing organizational safety climate. As climate improves, managers and employees are likely to agree more about the causes of safe/unsafe behaviors and workplace accidents, ultimately increasing their ability to work in unison to prevent accidents and to respond appropriately when they do occur. Finally, the survey items included in this study may be useful to organizations wishing to conduct self-assessments.     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

Stress and mental strain in hospital work: Exploring the relationship beyond personality

This study focuses on the relationship between job stressors and mental strain in hospital work, adjusting for differences in personality traits. Questionnaires were obtained from 760 full-time employees. Fourteen scales of job stressors were clustered into four factors: professional latitude, clinical demands, workload problems and role difficulties. A mental strain index was derived from the addition of three sub-scales: depression, anxiety and irritation. Two personality traits were measured: Locus of Control (Rotter) and Striver-Achiever (Sales). The four job demand factors were dichotomized into high-low grouping variables. A 2⁴ factorial analysis of covariance was conducted, using the two personality traits as covariates, in order to test and adjust for trait-related strain. Results show that Locus of Control adjusted differences in mental strain appear significantly related to work stressors. A direct relationship was found with role difficulties, professional latitude and workload problems. Moreover, high levels of role difficulties and low levels of professional latitude interact significantly with adjusted levels of mental strain. The Striver-Achiever trait, however, appears most strongly correlated with workload problems but not with mental strain. We believe that this exploratory analysis suggests that the stressor-strain relationship might be best conceived as a combination of direct and complex pathways, relating facets of both job demands and of personality with outcomes, under a cognitive and conditional paradigm.     

Applying systems thinking to analyze and learn from events

Major accidents keep occurring that seem preventable and that have similar systemic causes. Too often, we fail to learn from the past and make inadequate changes in response to losses. Examining the assumptions and paradigms underlying safety engineering may help identify the problem. The assumptions questioned in this paper involve four different areas: definitions of safety and its relationship to reliability, accident causality models, retrospective vs. prospective analysis, and operator error. Alternatives based on systems thinking are proposed.     

油库火灾原因分析

油库火灾爆炸事故除易造成人员中毒、伤亡、经济损失巨大外,还会导致环境污染严重。近十年来油罐单罐面积越来越大,油库火灾爆炸发生的次数和损失与2000年以前相比急剧增长,特别是对环境的污染日益引起人们的重视。通过对23起油库火灾爆炸事故案例进行分析,发现静电是引发油库火灾爆炸几率最大的火源,输、卸油是最易引发油库火灾的操作工艺,人为的操作失误是油库发生火灾爆炸事故的主要原因。探索油库火灾爆炸事故发生的原因,对减少、避免同类事故的发生具有重要价值和意义。     

视屏显示终端作业的健康问题及其对策

视屏显示终端作业不仅提高了人—机—环境系统的信息传递效率。减轻了操作者的劳动负荷,也带来了若干有损健康的问题,如眼睛疲劳,职业性肌肉骨骼慢性疾患,职业性应激。对此进行讨论。提出对策,并就开展我国VDT作业健康研究阐述了看法。     

Thought self-leadership: The influence of self-talk and mental imagery on performance

Self-leadership theory can be described as the ‘process of influencing oneself ’as opposed to the influence of leaders over followers (Manz, 1983, 1986). We focus on and develop a model for a particular aspect of self-leadership — thought self-leadership — emphasizing two primary elements, self-talk and mental imagery. The major thrust of this model is that employees can influence or lead themselves by utilizing specific cognitive strategies that focus on individual self-dialogue and mental imagery. It is proposed that constructive thought management through the effective application of cognitive strategies can lead to enhanced individual and organizational performance.     

Worker safety and injury severity analysis of earthmoving equipment accidents

Introduction: Research on construction worker safety associated with construction equipment has mostly focused on accident type rather than injury severity and the embedded factor relationships. Significant variables and their effects on the degree of injury are examined for earthmoving equipment using data from OSHA. Four types of equipment, backhoe, bulldozer, excavator, and scraper are included in the study. Accidents involving on-foot workers and equipment operators are investigated collectively, as well as separately. Methods: Cross tabulation analysis was conducted to establish the associations between selected categorical variables, using degree of injury as a dichotomous dependent variable (fatal vs. nonfatal) and a number of independent variables having different values. Odds ratios were calculated to determine how much a certain variable/factor increases the odds of fatality in an accident, and the odds ratios were ranked to determine the relative impact of a given factor. Results: It was found that twelve variables were significantly associated with injury severity. Rankings based on odds ratios showed that inadequate safety training (2.54), missing equipment protective system (2.38), being a non-union worker (2.26), being an equipment operator (1.93), and being on or around inadequately maintained equipment (1.58) produced higher odds for fatality. Conclusion: A majority of the earthmoving equipment accidents resulted in fatality. Backhoes were the most common equipment involved in accidents and fatalities. Struck-by accidents were the most prevalent and most fatal. Non-OSHA compliant safety training, missing seatbelt, operator not using seatbelt, malfunctioning back-up alarms, and poorly maintained equipment were factors contributing to accidents and fatalities. On-foot workers experienced a higher number of accidents than operators, while fatality odds were higher for the operators. Practical applications: Safety professionals should benefit from our findings in planning and delivering training and providing oversight to workers in earthmoving equipment operations.     

Ergodynamics and Hybrid Intelligence Systems in the Reliability of Power Plant Operators

Based on ergodynamics and the hybrid intelligence theory, an analysis of the nuclear power plant operator’s performance is given at the levels of strategies, tactics, and actions. Special attention is paid to the strategies used in the course of severe accidents at nuclear power plants. Data from Ukrainian and Russian power plants and training centres and from accidents around the world were collected and processed. It is shown that in an emergency it is essential for the human operator to be flexible. This flexibility includes two main training and personal factors: a large set of strategies and tactics the operator manages to use, and quick transformations between the strategies (tactics). It was also found that some emergency tasks are too complicated: They require simultaneous use of different strategies, with time strictly limited by nuclear power plant dynamics. Those tasks cannot be successfully solved by any individual operator. Hybrid intelligence systems involving different specialists should be used in those cases in order to avoid failures in emergency problem solving.     

Dynamic approach to risk management: Application to the Hoeganaes metal dust accidents

Several major accidents caused by metal dusts were recorded in the past few years. For instance, in 2011, three accidents caused by iron dust killed five workers at the Hoeganaes Corp. facility in Gallatin, Tennessee (USA). In order to prevent such accidents, a dynamic approach to risk management was defined in this study. The method is able to take into account new risk notions and early warnings and to systematically update the related risk. It may be applied not only in the design phase of a system, but also throughout the system lifetime as a support to a more precise and robust decision making process. The synergy of two specific techniques for hazard identification and risk assessment was obtained: the Dynamic Procedure for Atypical Scenarios Identification (DyPASI) and the Dynamic Risk Assessment (DRA) methods. To demonstrate its effectiveness, this approach was applied to the analysis of Gallatin metal dust accidents. The application allowed collecting a number of risk notions related to the plant, equipment and materials used. The analysis of risk notions by means of this dynamic approach could have led to enhanced hazard identification and dynamic real-time risk assessment. However, the approach described is effective only if associated to a proper safety culture, in order to produce an appropriate and robust decision making response to emerging risk issues.     

如何提高大型游乐设施设备本质安全

大型游乐设施事故主要是由于人的不安全行为和物的不安全状态导致的﹐目前部分设计制造单位对游乐设施危险源识别不充分﹐风险分析不到位﹐防控措施流于形式,不能从设计制造阶段彻底消除不安全因素,希望使用单位的规范管理来规避风险﹐这不能从根本上控制风险﹐游客和作业人员的不安全行为必须通过设备本体的安全功能来约束和控制。本文结合标准和案例探讨如何提高设备本质安全﹐以实现从源头控制。     

新型矿用救生舱空气调节系统研究与设计

救生舱是有效减少井下各种灾害导致人员伤亡的安全设施设备,调节救生舱内的温度是保障矿工生存的重要措施。通过对矿用救生舱热负荷的分析计算和矿用救生舱空气调节系统研究现状的分析,设计了以液态二氧化碳相变制冷为基础的两种空气调节系统,可在无需电力驱动、相对狭小空间配套的情况下,适合作为救生舱的空气调节系统。该系统的研发将会解决矿用救生舱在无电力驱动情况下的温度调节问题。     

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.