scholarly journals Analysis of “2·28” KEEPER Chemical Industries Hazardous Chemical Explosion Accident Based on FTA and HFACS

2018 ◽  
Vol 15 (10) ◽  
pp. 2151 ◽  
Author(s):  
Wei Jiang ◽  
Wei Han
Keyword(s):  
Human Factors ◽  
Fault Tree ◽  
Fault Tree Analysis ◽  
Organizational Influences ◽  
Hazardous Chemical ◽  
Factors Analysis ◽  
Logic Diagram ◽  
Guanidine Nitrate ◽  
Tree Diagram ◽  
Chemical Explosion

On 28 February 2012, a guanidine nitrate explosion occurred at HEBEI KEEPER Chemical Industries Co., Ltd., China, resulting in 25 deaths, with 4 missing individuals and 46 injured. In order to explore the causal relationship hidden behind this accident, fault tree analysis (FTA) and the Human Factors Analysis and Classification System (HFACS) were used to systematically analyze the incident. Firstly, FTA was used to analyze the causes of the accident in depth, until all the basic causal events causing the guanidine nitrate explosion were identified, and a fault tree diagram of the guanidine nitrate explosion was drawn. Secondly, for the unsafe acts in the basic causal events, the HFACS model was used to analyze the three levels of factors that lead to unsafe acts, including the preconditions for unsafe acts, unsafe supervision, and organizational influences. Finally, based on the analysis results of FTA and HFACS, a complete logic diagram of the causes of the accident was obtained. The FTA and HFACS accident analysis methods allowed for the identification of human factors and the accident evolution process in the explosion accident and provide a reference for accident investigation.

Human Factors Analysis of Infection Prevention Practices in the Anesthesia Work Environment

2017 ◽  
Vol 61 (1) ◽  
pp. 639-642
Author(s):  
Ella Franklin ◽  
Lucy Stein
Keyword(s):  
Human Factors ◽  
Work Environment ◽  
Operating Room ◽  
Physical Environment ◽  
Infection Prevention ◽  
Pathogen Transmission ◽  
Organizational Influences ◽  
Space Design ◽  
Factors Analysis ◽  
Emerging Themes

The department of anesthesia for a Washington, D.C. hospital engaged the MedStar National Center for Human Factors in Healthcare to identify opportunities for improving the anesthesia work environment with aims to mitigate the risk of pathogen transmission during operating room procedures. The human factors approach included operating room visits for observation and thematic analysis to identify emerging themes. Process inconsistencies in hand hygiene and cleaning practices were indicative of system vulnerabilities, including organizational influences and the design of the physical environment. Work-space design recommendations as well as strategies to improve infection control processes and safety culture are presented.

scholarly journals Applications of FFTA–HFACS for Analyzing Human and Organization Factors in Electric Misoperation Accidents

2021 ◽  
Vol 11 (19) ◽  
pp. 9008
Author(s):  
Chuan Lin ◽  
Qifeng Xu ◽  
Yifan Huang
Keyword(s):  
Risk Factors ◽  
Human Factors ◽  
Hybrid Method ◽  
Fault Tree ◽  
Fault Tree Analysis ◽  
Organizational Factors ◽  
Risk Level ◽  
Accident Risk ◽  
Fuzzy Aggregation ◽  
Failure Probabilities

Human and organizational factors (HOFs) play an important role in electric misoperation accidents (EMAs), but research into the reliability of human factors is still in its infancy in the field of EMAs, and further investment in research is urgently required. To analyze the HOFs in EMAs, a hybrid method including the Human Factors Analysis and Classification System (HFACS) and fuzzy fault tree analysis (FFTA) was applied to EMAs for the first time in the paper. HFACS is used to identify and classify the HOFs with 135 accidents, reorganized as basic events (BEs), intermediate events (IEs), and top event (TE), and develop the architecture of fault tree (FT). Fuzzy aggregation is employed to address experts’ expressions and obtain the failure probabilities of the BEs and the minimal cut sets (MCSs) of the FT. The approach generates BEs failure probabilities without reliance on quantitative historical failure statistics of EMAs via qualitative records processing. The FFTA–HFACS model is applied for quantitative analysis of the probability of failure of electrical mishaps and the interaction between accident risk factors. It can assist professionals in deciding whether and where to take preventive or corrective actions and assist in knowledgeable decision-making around the electric operation and maintenance process. Finally, applying this hybrid method to EMAs, the results show that the probability of an EMAs is 1.0410 × 10−2, which is a risk level that is likely to occur and must be controlled. Two of the most important risk factors are habitual violations and supervisory violation; a combination of risk factors of inadequate work preparation and paralysis, and irresponsibility on the part of employees are also frequent errors.

Using HFACS-Healthcare to Identify Systemic Vulnerabilities During Surgery

2018 ◽  
Vol 33 (6) ◽  
pp. 614-622 ◽  
Author(s):  
Tara N. Cohen ◽  
Sarah E. Francis ◽  
Douglas A. Wiegmann ◽  
Scott A. Shappell ◽  
Bruce L. Gewertz
Keyword(s):  
Patient Safety ◽  
Human Factors ◽  
Reporting System ◽  
Near Miss ◽  
Causal Factors ◽  
Event Reporting ◽  
Near Misses ◽  
Process Improvements ◽  
Organizational Influences ◽  
Factors Analysis

The Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare) was used to classify surgical near miss events reported via a hospital’s event reporting system over the course of 1 year. Two trained analysts identified causal factors within each event narrative and subsequently categorized the events using HFACS-Healthcare. Of 910 original events, 592 could be analyzed further using HFACS-Healthcare, resulting in the identification of 726 causal factors. Most issues (n = 436, 60.00%) involved preconditions for unsafe acts, followed by unsafe acts (n = 257, 35.39%), organizational influences (n = 27, 3.72%), and supervisory factors (n = 6, 0.82%). These findings go beyond the traditional methods of trending incident data that typically focus on documenting the frequency of their occurrence. Analyzing near misses based on their underlying contributing human factors affords a greater opportunity to develop process improvements to reduce reoccurrence and better provide patient safety approaches.

scholarly journals Ship accident prevention under organizational influences on the ship operation by using gap analysis

2019 ◽  
Author(s):  
Dwi Antoro ◽  
Bambang Eka W ◽  
Antoni Arif Priadi
Keyword(s):  
Human Factors ◽  
Human Factor ◽  
Gap Analysis ◽  
Accident Prevention ◽  
Analysis Method ◽  
Prevention Strategies ◽  
Organizational Policies ◽  
Organizational Influences ◽  
Factors Analysis ◽  
Ship Operation

By using Human Factors Analysis and Classification System (HFACS), the identification of human factor could be analyzed and classified to find out some prevention actions against ship accident. The human factors may play an important role in ship accident as the consequences of the ship operation is the risk that can potentially happen. One of the layers of HFACS is the organization influences which consist of factors such as human resources, organization climate, and policies. The objective of this research was to identify and to explore the perception and the expectation of the ship officer related to organizational influences by applying gap analysis method. The questionnaire consisted of 28 questions divided into three categories. The result showed that the policies factor has higher gap compared with the others factors. The result indicated that the shipping company need to pay more attention to the condition of organizational policies before recruiting new crews, as well as the policies related to the monitoring while they are on board and after they return home. Further research on similar method on others layers of HFACS need to be carried out in order to obtain more detailed descriptions on ship accident prevention strategies.

An Application of the HFACS Method to Aviation Accidents in Africa

2016 ◽  
Vol 6 (1) ◽  
pp. 33-38 ◽  
Author(s):  
Isaac Munene
Keyword(s):  
Human Factors ◽  
Physical Environment ◽  
Human Factor ◽  
Flight Training ◽  
African Countries ◽  
Causal Factors ◽  
Aviation Accidents ◽  
Factors Analysis ◽  
Adverse Weather ◽  
Decision Errors

Abstract. The Human Factors Analysis and Classification System (HFACS) methodology was applied to accident reports from three African countries: Kenya, Nigeria, and South Africa. In all, 55 of 72 finalized reports for accidents occurring between 2000 and 2014 were analyzed. In most of the accidents, one or more human factors contributed to the accident. Skill-based errors (56.4%), the physical environment (36.4%), and violations (20%) were the most common causal factors in the accidents. Decision errors comprised 18.2%, while perceptual errors and crew resource management accounted for 10.9%. The results were consistent with previous industry observations: Over 70% of aviation accidents have human factor causes. Adverse weather was seen to be a common secondary casual factor. Changes in flight training and risk management methods may alleviate the high number of accidents in Africa.

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