Analysis and Estimation of Human Errors From Major Accident Investigation Reports

Author(s):  
Caroline Morais ◽  
Raphael Moura ◽  
Michael Beer ◽  
Edoardo Patelli

Abstract Risk analyses require proper consideration and quantification of the interaction between humans, organization, and technology in high-hazard industries. Quantitative human reliability analysis approaches require the estimation of human error probabilities (HEPs), often obtained from human performance data on different tasks in specific contexts (also known as performance shaping factors (PSFs)). Data on human errors are often collected from simulated scenarios, near-misses report systems, and experts with operational knowledge. However, these techniques usually miss the realistic context where human errors occur. The present research proposes a realistic and innovative approach for estimating HEPs using data from major accident investigation reports. The approach is based on Bayesian Networks used to model the relationship between performance shaping factors and human errors. The proposed methodology allows minimizing the expert judgment of HEPs, by using a strategy that is able to accommodate the possibility of having no information to represent some conditional dependencies within some variables. Therefore, the approach increases the transparency about the uncertainties of the human error probability estimations. The approach also allows identifying the most influential performance shaping factors, supporting assessors to recommend improvements or extra controls in risk assessments. Formal verification and validation processes are also presented.

2020 ◽  
Vol 142 (6) ◽  
Author(s):  
Danilo Taverna Martins Pereira de Abreu ◽  
Marcos Coelho Maturana ◽  
Enrique Andrés López Droguett ◽  
Marcelo Ramos Martins

Abstract During a ship life cycle, one of the most critical phases in terms of safety refers to harbor maneuvers, which take place in restricted and congested waters, leading to higher collision and grounding risks in comparison to open sea navigation. In this scenario, a single accident may stop the harbor's traffic as well as incur in patrimonial damage, environmental pollution, human casualties, and reputation losses. In order to support the vessel's captain during the maneuver, local experienced maritime pilots stay on board coordinating the ship navigation while in restricted waters. Aiming to assess the main factors contributing to human errors in pilot-assisted harbor ship maneuvers, this work proposes a Bayesian network model for human reliability analysis (HRA), supported by a prospective human performance model for quantification. The novelty of this work resides into two aspects: (a) incorporation of harbor specific conditions for maritime navigation HRA, including the performance of ship's crew and maritime pilots and (b) the use of a prospective human performance model as an alternative to expert's opinion for quantification purposes. To illustrate the usage of the proposed methodology, this paper presents an analysis of the route keeping task along waterways, starting from the quantification of human error probabilities (HEP) and including the ranking of the main performance shaping factors that contribute to the HEP.


2013 ◽  
Vol 2013 ◽  
pp. 1-8 ◽  
Author(s):  
Renato A. Fonseca ◽  
Antonio Carlos M. Alvim ◽  
Paulo Fernando F. Frutuoso e Melo ◽  
Marco Antonio B. Alvarenga

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.


1981 ◽  
Vol 25 (1) ◽  
pp. 105-109
Author(s):  
A. Mohsen M. Metwally ◽  
Zeinab A. Sabri ◽  
S. Keith Adams ◽  
Abdo A. Husseiny

Two techniques useful for the simulation and analysis of human performance in tasks involving nuclear power plant operation, maintenance and testing are evaluated. The SAINT and THERP techniques are compared with respect to their relevance to conducting task analysis, estimation of human error probabilities and accounting for performance shaping factors in nuclear power plants. The results show that the SAINT is more flexible and has promising features for human engineering studies of complex systems when compared to the static THERP technique currently used in nuclear safety analysis.


Author(s):  
Danilo T. M. P. Abreu ◽  
Marcos C. Maturana ◽  
Marcelo R. Martins ◽  
Siegberto R. Schenk

Abstract During a ship life cycle, one of the most critical phases in terms of safety refers to harbor maneuvers, which take place in restricted and congested waters, leading to higher collision and grounding risks in comparison to open sea navigation. In this scenario, a single accident may stop the harbor’s traffic as well as incur into patrimonial damage, environmental pollution, human casualties and reputation losses. In order to support the vessel’s captain during the maneuver, local experienced maritime pilots stay on board coordinating the ship navigation while in restricted waters. Because of their shorter relative duration, harbor maneuvers accidents are more probable to occur due to human errors — reinforced by the inherent surrounding difficulties —, rather than machinery failures, for instance. The human errors are object of study of the human reliability analysis (HRA). Aiming to assess the main factors contributing to human errors in pilot-assisted harbor ship maneuvers, this work proposes a Bayesian network model for HRA, supported by a prospective human performance model for quantification. Similar works focus mainly on open sea navigation and collision accidents, which do not reflect the strict conditions found on port areas. Additionally, most of the models are highly dependent on expert’s opinion for quantification. Therefore, the novelty of this work resides into two aspects: a) incorporation of harbor specific conditions for maritime navigation HRA, including the performance of ship’s crew and maritime pilots; and b) the use of a prospective human performance model as an alternative to expert’s opinion for quantification purposes. To illustrate the usage of the proposed methodology, this paper presents an analysis of the route keeping task along waterways, starting from the quantification of human error probabilities (HEP) and including the ranking of the main external factors that contribute to the HEP.


2021 ◽  
Vol 11 (2) ◽  
pp. 749
Author(s):  
Yaniel Torres ◽  
Sylvie Nadeau ◽  
Kurt Landau

Manual assembly operations are sensitive to human errors that can diminish the quality of final products. The paper shows an application of human reliability analysis in a realistic manufacturing context to identify where and why manual assembly errors occur. The techniques SHERPA and HEART were used to perform the analysis of human reliability. Three critical tasks were selected for analysis based on quality records: (1) installation of three types of brackets using fasteners, (2) fixation of a data cable to the assembly structure using cushioned loop clamps and (3) installation of cap covers to protect inlets. The identified error modes with SHERPA were: 36 action errors, nine selection errors, eight information retrieval errors and six checking errors. According to HEART, the highest human error probabilities were associated with assembly parts sensitive to geometry-related errors (brackets and cushioned loop clamps). The study showed that perceptually engaging assembly instructions seem to offer the highest potential for error reduction and performance improvement. Other identified areas of action were the improvement of the inspection process and workers’ provision with better tracking and better feedback. Implementation of assembly guidance systems could potentially benefit worker’s performance and decrease assembly errors.


Author(s):  
Victor G. Krymsky ◽  
Farit M. Akhmedzhanov

Abstract The well-known standardized plant analysis risk-human reliability (SPAR-H) methodology is widely used for analysis of human reliability in complex technological systems. It allows assessing the human error probability taking into account eight important groups of performance shaping factors. Application of this methodology to practical problems traditionally involves assumptions which are difficult to verify under the conditions of uncertainty. In particular, it introduces only two possible values of the nominal human error probabilities (for diagnosis and for actions) which do not cover the whole spectrum of the tasks within operator's activity. In addition, although the traditional methodology considers the probabilities of human errors as the random variables, it operates only on a single predefined type of distribution for these variables and does not deal with the real situations in which the type of distribution remains uncertain. The paper proposes modification to the classical approach to enable more adequate modeling of real situations with the lack of available information. The authors suggest usage of the interval-valued probability technique and of the expert judgment on the maximum probability density for actual probabilities of human errors. Such methodology allows obtaining generic results that are valid for the entire set of possible distributions (not only for one of them). The modified methodology gives possibility to derive final assessments of human reliability in interval form indicating “the best case” and “the worst case.” A few numerical examples illustrate the main stages of the suggested procedure.


2019 ◽  
Vol 12 (1) ◽  
pp. 115 ◽  
Author(s):  
Chiara Franciosi ◽  
Valentina Di Pasquale ◽  
Raffaele Iannone ◽  
Salvatore Miranda

Purpose: Human factors play an inevitable role in maintenance activities, and the occurrence of Human Errors (HEs) affects system reliability and safety, equipment performance and economic results. The high HE rate increased researchers’ attention towards Human Reliability Analysis (HRA) and HE assessment approaches. In these approaches, various environmental and individual factors influence the performance of maintenance operators affecting Human Error Probability (HEP) with a consequent variability in the success of intervention. However, a deep analysis of such factors in the maintenance field, often called Performance Shaping Factors (PSFs), is still missing. This has led the authors to systematically evaluate the literature on Human Error in Maintenance (HEM) and on the PSFs, in order to provide a shared PSF taxonomy.Design/methodology/approach: A Systematic Literature Review (SLR) was conducted to identify and select peer-reviewed papers that provided evidence on the relationship between maintenance activities and human performance. The obtained results provided a wide overview in the field of interest, shedding light on three main research areas of investigation: methodologies for human error analysis in maintenance, performance shaping factors and maintenance error consequences. In particular, papers belonging to the area of PSFs were analysed in-depth in order to identify and classify the PSFs, with the aim of achieving the PSF taxonomy for maintenance activities. The effects of each PSF on human reliability were defined and detailed.Findings: A total of 63 studies were selected and then analysed through a systematic methodology. 46% of these studies presented a qualitative/quantitative assessment of PSFs through application in different maintenance activities. Starting from the findings of the aforementioned papers, a PSF taxonomy specific for maintenance activities was proposed. This taxonomy represents an important contribution for researchers and practitioners towards the improvement of HRA methods and their applications in industrial maintenance.Originality/value: The analysis outlines the relevance of considering HEM because different error types occur during the maintenance process with non-negligible effects on the system. Despite a growing interest in HE assessment in maintenance, a deep analysis of PSFs in this field and a shared PSF taxonomy are missing. This paper fills the gap in the literature with the creation of a PSF taxonomy in industrial maintenance. The proposed taxonomy is a valuable contribution for growing the awareness of researchers and practitioners about factors influencing maintainers’ performance.


2008 ◽  
Vol 2008 ◽  
pp. 1-7 ◽  
Author(s):  
Marko Čepin

The human reliability analysis (HRA) is a highly subjective evaluation of human performance, which is an input for probabilistic safety assessment, which deals with many parameters of high uncertainty. The objective of this paper is to show that subjectivism can have a large impact on human reliability results and consequently on probabilistic safety assessment results and applications. The objective is to identify the key features, which may decrease subjectivity of human reliability analysis. Human reliability methods are compared with focus on dependency comparison between Institute Jožef Stefan human reliability analysis (IJS-HRA) and standardized plant analysis risk human reliability analysis (SPAR-H). Results show large differences in the calculated human error probabilities for the same events within the same probabilistic safety assessment, which are the consequence of subjectivity. The subjectivity can be reduced by development of more detailed guidelines for human reliability analysis with many practical examples for all steps of the process of evaluation of human performance.


2011 ◽  
Vol 97-98 ◽  
pp. 825-830 ◽  
Author(s):  
Yong Tao Xi ◽  
Chong Guo

Safety is the eternal theme in shipping industry. Research shows that human error is the main reason of maritime accidents. Therefore, it is very necessary to research marine human errors, to discuss the contexts which caused human errors and how the contexts effect human behavior. Based on the detailed investigation of human errors in collision avoidance behavior which is the most key mission in navigation and the Performance Shaping Factors (PSFs), human reliability of mariners in collision avoidance was analyzed by using the integration of APJE and SLIM. Result shows that this combined method is effective and can be used for the research of maritime human reliability.


Author(s):  
Oladokun Sulaiman Olanrewaju

The traditional approach to the study of human factors in the maritime field involves the analysis of accidents without considering human factor reliability analysis. The main approaches being used to analyze human errors are statistical approach and probability theory approach. Another suitable approach to the study of human factors in the maritime industry is the quasi-experimental field study where variations in performance (for example attention) can be observed as a function of natural variations in performance shaping factors. This chapter analyzes result of modelling for human error and human reliability emanating from the use of technology on board ship navigation in coastal water areas by using qualitative and quantitative tools. Accident reports from marine department are used as empirical material for quantitative analysis. The literature on safety is based on common themes of accidents, the influence of human error resulting from technology usage design, accident reports from MAIB, and interventions information are used for qualitative assessment. Human reliability assessment involves analysis of accidents in waterways emanating from human-technology factors. The chapter reports enhancement requirement of the methodological issues with previous research study, monitoring, and deduces recommendations for technology modification of the human factors necessary to improve maritime safety performance. The result presented can contribute to rule making and safety management leading to the development of guidelines and standards for human reliability risk management for ships navigating within inland and coastal waters.


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