scholarly journals Incorporating Human Reliability Analysis to enhance Maintenance Audits: The Case of Rail Bogie Maintenance

2020 ◽  
Vol 8 (3) ◽  
Author(s):  
Sarbjeet Singh ◽  
Arnab Majumdar ◽  
Miltos Kyriakidis
Keyword(s):  
Human Error ◽  
Time Pressure ◽  
Fault Tree Analysis ◽  
Disc Brake ◽  
Human Reliability Analysis ◽  
Bogie Frame ◽  
Human Errors ◽  
Management Personnel ◽  
Assembly Unit ◽  
Railway Maintenance

Human errors occurring during railway maintenance activities can significantly reduce the availability of equipment. Identification of potential human errors, their causes and prediction of the associated probabilities are important stages in order to manage such errors. This paper investigates the probability of human error during the maintenance of railway bogies. A case study examines technicians performing maintenance on the disc brake assembly unit, wheel set, and bogie frame under various error producing conditions in a railway maintenance workshop in Luleå, Sweden. The Human Error Assessment and Reduction Technique (HEART) is employed to determine the probability of human error occurring during each of the maintenance tasks, while fault tree analysis is used to define the potential errors throughout the maintenance process. The probability of a technician committing an error during the maintenance of the disc brake assembly, wheel set, and bogie frame is found to be 0.20, 0.039 and 0.021 respectively, with the human error probability (HEP) for the entire bogie 0.24. Time pressure, ability to detect and perceive problems, over-riding information, the need to make decisions and mismatches between the operator and designer’s model turn out to be major contributors to human error. These findings can help maintenance management personnel to better understand the error producing conditions that may lead to errors and in turn serve as an input to modify policies and guidelines for railway maintenance tasks.

scholarly journals Causes and Impact of Human Error in Maintenance of Mechanical Systems

2020 ◽  
Vol 312 ◽  
pp. 05001
Author(s):  
Mfundo Nkosi ◽  
Kapil Gupta ◽  
Madindwa Mashinini
Keyword(s):  
Human Error ◽  
Time Pressure ◽  
Preventive Measures ◽  
Negative Impact ◽  
Mechanical Systems ◽  
Economic Losses ◽  
Human Errors ◽  
Communication Time ◽  
High Standards ◽  
Pressure Plant

The concept of minimizing human error in maintenance is progressively gaining attention in various industries. The incorporation of human factors when solving engineering problems, particularly in maintenance, can no longer be ignored where high standards of performance are expected. The journey of improving maintenance performance through the reduction of human error begins with the understanding of causes and impact of human error in maintenance. This paper evaluates previous scholarly writings on human errors, to specifically establish the causes and impact of human error in maintenance. This study relies predominantly on the existing literature on human error in maintenance derived from published and unpublished research. The primary findings emerging from the research exhibit a number of key factors that cause a human error in maintenance such as poor management and supervision, organizational culture, incompetence, poorly written procedures, poor communication, time pressure, plant and environmental conditions, poor work design and many more. The literature review also revealed that human errors have a negative impact on safety, reliability, productivity and efficiency of the equipment. It was further discovered that equipment failures leading to accidents, incidents, loss of life and economic losses are the major effects of human error. Human error in mechanical systems’ maintenance is a serious problem which needs adequate attention in order to develop corrective and preventive measures. This review paper serves as a basis for maintenance practitioners and interested parties to develop corrective and preventive measures for minimizing human error in the maintenance of mechanical systems.

Revisiting the FPSO São Mateus Accident From a Human Reliability Perspective Using Phoenix HRA Methodology

2020 ◽  
Author(s):  
Marilia A. Ramos ◽  
Alex Almeida ◽  
Marcelo R. Martins
Keyword(s):  
Human Error ◽  
Oil And Gas ◽  
Risk Estimation ◽  
Petroleum Industry ◽  
Oil And Gas Industry ◽  
Qualitative Assessment ◽  
Human Reliability ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Gas Industry

Abstract Several incidents in the offshore oil and gas industry have human errors among core events in incident sequence. Nonetheless, human error probabilities are frequently neglected by offshore risk estimation. Human Reliability Analysis (HRA) allows human failures to be assessed both qualitatively and quantitatively. In the petroleum industry, HRA is usually applied using generic methods developed for other types of operation. Yet, those may not sufficiently represent the particularities of the oil and gas industry. Phoenix is a model-based HRA method, designed to address limitations of other HRA methods. Its qualitative framework consists of three layers of analysis composed by a Crew Response Tree, a human response model, and a causal model. This paper applies a version of Phoenix, the Phoenix for Petroleum Refining Operations (Phoenix-PRO), to perform a qualitative assessment of human errors in the CDSM explosion. The CDSM was a FPSO designed to produce natural gas and oil to Petrobras in Brazil. On 2015 an explosion occurred leading to nine fatalities. Analyses of this accident have indicated a strong contribution of human errors. In addition to the application of the method, this paper discusses its suitability for offshore operations HRA analyses.

UNCERTAINTY OF HUMAN ERROR AND FUZZY APPROACH TO HUMAN RELIABILITY ANALYSIS

2006 ◽  
Vol 14 (01) ◽  
pp. 111-129 ◽  
Author(s):  
B. J. KIM ◽  
RAM R. BISHU
Keyword(s):  
Reliability Analysis ◽  
Nuclear Power ◽  
Power Plants ◽  
Human Error ◽  
Critical Factor ◽  
Fuzzy Approach ◽  
Human Reliability ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Fuzzy Logic Approach

Human error is regarded as a critical factor in catastrophic accidents such as disasters at nuclear power plants, air plane crashes, or derailed trains. Several taxonomies for human errors and methodologies for human reliability analysis (HRA) have been proposed in the literature. Generally, human errors have been modeled on the basis of probabilistic concepts with or without the consideration of cognitive aspects of human behaviors. Modeling of human errors through probabilistic approaches has shown a limitation on quantification of qualitative aspects of human errors and complexity of attributes from circumstances involved. The purpose of this paper is to investigate the methodologies for human reliability analysis and introduce a fuzzy logic approach to the evaluation of human interacting system's reliability. Fuzzy approach could be used to estimate human error effects under ambiguous interacting environments and assist in the design of error free work environments.

Analysis and Estimation of Human Errors From Major Accident Investigation Reports

2019 ◽  
Vol 6 (1) ◽  
Author(s):  
Caroline Morais ◽  
Raphael Moura ◽  
Michael Beer ◽  
Edoardo Patelli
Keyword(s):  
Human Error ◽  
Human Performance ◽  
Accident Investigation ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Near Misses ◽  
Performance Shaping Factors ◽  
Major Accident ◽  
Using Data ◽  
Error Probabilities

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.

scholarly journals A THERP/ATHEANA Analysis of the Latent Operator Error in Leaving EFW Valves Closed in the TMI-2 Accident

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
Keyword(s):  
Human Error ◽  
Feed Water ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Operator Error ◽  
Permanent Loss ◽  
Error Probabilities ◽  
Comprehensive Modeling ◽  
Accident Sequences ◽  
Prior Analysis

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.

scholarly journals IDENTIFIKASI POTENSI BAHAYA DAN TEKNOLOGI KESELAMATAN KERJA PADA OPERASI PERIKANAN PAYANG DI PALABUHANRATU, JAWA BARAT

2013 ◽  
Vol 8 (2) ◽  
pp. 60
Author(s):  
Fis Purwangka ◽  
Sugeng Hari Wisudo ◽  
Budhi H. Iskandar ◽  
John Haluan
Keyword(s):  
Task Analysis ◽  
Safety Assessment ◽  
Human Error ◽  
Fault Tree Analysis ◽  
Reduction Technique ◽  
Error Assessment ◽  
Human Reliability Analysis ◽  
Hierarchical Task Analysis ◽  
Tree Analysis ◽  
Formal Safety Assessment

Penyebab utama kecelakaan laut yang berujung pada hilangnya nyawa manusia adalah murni kesalahan manusia (human error). Penyebab lainnya adalah pengabaian yang dilakukan oleh penyelenggara transportasi laut dan instansi-instansi terkait, serta perlengkapan keselamatan transportasi laut yang jauh dari memadai.  Khusus pada kegiatan perikanan, sebanyak 80 persen faktor kecelakaan laut disebabkan oleh kealpaan manusia.  Tulisan ini bertujuan untuk mengetahui potensi bahaya pada teknologi penangkapan ikan yang saat ini digunakan nelayan dengan mengidentifikasi risiko keselamatan kerja nelayan yang disebabkan oleh human error dan melakukan pengukuran kemungkinan terjadinya human error serta memberikan rekomendasi untuk mengurangi risiko yang disebabkan oleh human error.  Metode yang digunakan dalam penelitian ini adalah Formal Safety Assessment (FSA) dengan melakukan pengamatan langsung aktivitas penangkapan ikan pada perikanan payang.  Unsur manusia dapat dimasukkan ke dalam proses FSA dengan menggunakan analisis keandalan manusia (Human Reliability Analysis).  Tahapan HRA yang dilakukan adalah dengan mengidentifikasi aktivitas/tugas secara rinci dengan Hierarchical Task Analysis (HTA).  Tahap kedua adalah melakukan penilaian risiko dengan menggunakan Human error Assessment and Reduction Technique (HEART).  Tahap yang terakhir adalah memilih opsi pengendalian risiko yang konsisten terhadap aktivitas yang diamati dengan menggunakan Fault Tree Analysis (FTA).  Aktivitas yang memiliki peluang risiko terbesar terjadi pada aktivitas pengoperasian alat tangkap pada saat pemasangan (setting) alat tangkap.  Peluang konsekuensi kecelakaan kerja terbesar adalah aktivitas pengangkatan alat tangkap (hauling). Pilihan minimalisasi human error, secara umum adalah dengan melakukan perencanaan pelayaran, pemilihan ABK yang kompeten, melakukan aktivitas secara aman dan mempersiapkan alat perlindungan diri (APD) saat melakukan aktivitas atau berada di atas perahu.

scholarly journals Fuzzy Logic in HEART and CREAM Methods to Assess Human Error and Find an Optimum Method Using a Hierarchical Fuzzy System: A Case Study in a Steel Factory

2022 ◽  
Author(s):  
REZIE BOROUN ◽  
YASER TAHMASBI BIRGANI ◽  
ZEINAB MOSAVIANASL ◽  
GHOLAM ABBAS SHIRALI
Keyword(s):  
Steel Industry ◽  
Fuzzy System ◽  
Human Error ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
System A ◽  
Technical Advances ◽  
Hierarchical Fuzzy System

Numerous studies have been conducted to assess the role of human errors in accidents in different industries. Human reliability analysis (HRA) has drawn a great deal of attention among safety engineers and risk assessment analyzers. Despite all technical advances and the development of processes, damaging and catastrophic accidents still happen in many industries. Human Error Assessment and Reduction Technique (HEART) and Cognitive Reliability and Error Analysis Method (CREAM) methods were compared with the hierarchical fuzzy system in a steel industry to investigate the human error. This study was carried out in a rolling unit of the steel industry, which has four control rooms, three shifts, and a total of 46 technicians and operators. After observing the work process, reviewing the documents, and interviewing each of the operators, the worksheets of each research method were completed. CREAM and HEART methods were defined in the hierarchical fuzzy system and the necessary rules were analyzed. The findings of the study indicated that CREAM was more successful than HEART in showing a better capability to capture task interactions and dependencies as well as logical estimation of the HEP in the plant studied. Given the nature of the tasks in the studied plant and interactions and dependencies among tasks, it seems that CREAM is a better method in comparison with the HEART method to identify errors and calculate the HEP.  

Human Reliability Analysis of Ship Maneuvers in Harbor Areas

2019 ◽  
Author(s):  
Danilo T. M. P. Abreu ◽  
Marcos C. Maturana ◽  
Marcelo R. Martins ◽  
Siegberto R. Schenk
Keyword(s):  
Reliability Analysis ◽  
Human Error ◽  
Human Performance ◽  
Performance Model ◽  
Human Reliability ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Ship Maneuvers ◽  
Open Sea ◽  
Expert’S Opinion

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.

scholarly journals Classification and Quantification of Human Error in Manufacturing: A Case Study in Complex Manual Assembly

2021 ◽  
Vol 11 (2) ◽  
pp. 749
Author(s):  
Yaniel Torres ◽  
Sylvie Nadeau ◽  
Kurt Landau
Keyword(s):  
Human Error ◽  
Human Reliability ◽  
Human Reliability Analysis ◽  
Manual Assembly ◽  
Human Errors ◽  
Assembly Instructions ◽  
Inspection Process ◽  
And Performance ◽  
Error Probabilities ◽  
Assembly Guidance

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.

Post-Accident Human Reliability Analysis and Control of Mine Hoisting System

2012 ◽  
Vol 616-618 ◽  
pp. 461-464
Author(s):  
Zhao Xia Liu ◽  
Lian Jun Chen
Keyword(s):  
Failure Probability ◽  
Human Error ◽  
Response Probability ◽  
Human Reliability ◽  
Human Reliability Analysis ◽  
Human Errors ◽  
Cognitive Failure ◽  
Hoisting System ◽  
Accident Consequence ◽  
And Control

Using the method of THERPand HCR this paper studies post- accident human error events of mine hoisting system which reflects accident consequence seriousness and accident treatment urgency. It ascertains cognitive failure probability P1, non-response probability P2 and the failure probability P3, and quantities and appraises degree of human reliability. Finally this paper analyzes causes of hoisting accident human errors ,by which probability human error can be reduced to the lowest limit.

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