Write your message
Volume 8, Issue 4 (Iranian Journal of Ergonomics 2021)                   Iran J Ergon 2021, 8(4): 31-49 | Back to browse issues page


XML Persian Abstract Print


Download citation:
BibTeX | RIS | EndNote | Medlars | ProCite | Reference Manager | RefWorks
Send citation to:

Mosavi Ghahfarokhi M, Afshari D, Shirali G A. Predictive Analysis of Cognitive Errors of Control Room Operators: a Case Study in a Petrochemical Industry. Iran J Ergon 2021; 8 (4) :31-49
URL: http://journal.iehfs.ir/article-1-758-en.html
1- Department of Safety and Occupational Health Engineering, Faculty of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
2- Department of Safety and Occupational Health Engineering, Faculty of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran , shirali@ajums.ac.ir
Abstract:   (5795 Views)

Background and Objectives: In recent decades, several major accidents have occurred in high-reliability industries such as petrochemical companies. Accident analysis shows that the occurrence of more than 90% of accidents in industries are due to human factor and only with technical-engineering measures and the establishment of safety rules and regulations can not be institutionalized safe behaviors in such industries. Therefore, despite a slight reduction in human presence in these industries, the potential for human error risks is still high. The aim of this study was to identify and assess human errors in a petrochemical plant using the technique for the retrospective and predictive analysis of cognitive errors (TRACEr).
Methods: The sample size was all the eight operators of control room working in four shifts. In the first step, all tasks were analyzed using the hierarchical task analysis in order to identify sub-tasks. Then, for all the subtasks, different error modes (external and internal), psychological error mechanism (PEM) and performance shaping factors (PSFs) were identified and recorded in TRACEr sheet.
Results: The analysis of TRACEr sheets indicated that of a total number of 1171 detected errors, the internal and external errors were 50.67% (n=593) and 49.33% (n=578), respectively. In this line, ̔timing/sequence̕ errors with 35.36% and 'quality/selection' errors with 30.03% were identified as the highest and lowest external error modes, respectively. In classifying the internal error modes, action errors with 31.87% and decision making with 10.73% were identified as the highest and lowest external error modes, respectively. Within PEMs, ̔distraction/preoccupation̓ (23.61%) was identified as the main causes of perception errors. The analysis of the PSFs shows that ‘Organization’ with 27.95% and ‘task complexity’ with 8.74% were two main factors affecting the task errors.
Conclusion: The current study could identify many of the errors and conditions that affect the performance of operators. Therefore, this study can be introduced as a basis for managers and stockholders of chemical industries with complexity and high risk in order to prioritize human error prevention programs.

Full-Text [PDF 788 kb]   (6918 Downloads)    
Type of Study: Review | Subject: Other Cases
Received: 2020/10/14 | Accepted: 2020/12/28 | ePublished: 2020/12/28

References
1. Macchi L, Hollnagel E, Leonhard J, editors. Resilience Engineering approach to safety assessment: an application of FRAM for the MSAW system. EUROCONTROL Safety R&D Seminar; 2009: EUROCONTROL. [Article]
2. Hollnagel E. Human Reliability Analysis: Context and Control. 1993. London: Academic Press. [Google Scholar]
3. Hoseini H. Human Error Engineering: Fanavaran; 2010.
4. Azhdari M, Monazami Tehrani G, Alibabaei A. Investigating the causes of human error-induced incidents in the maintenance operations of petrochemical industry by using HFACS. J. Occup. Hyg. Eng. 2017 Mar 10;3(4):22-30. [DOI]
5. Maulana FI, Widyanti A. Adaptation of Tracer-Technique for The Retrospective and Predictive Analysis of Cognitive Errors-for Analyzing Indonesian Train Accident Involving Train Dispatcher. InJournal of Physics: Conference Series 2019 Mar 1 (Vol. 1175, No. 1, p. 012193). IOP Publishing. [DOI]
6. Khan FI, Abbasi SA. Techniques and methodologies for risk analysis in chemical process industries. J Loss Prev Process Ind. 1998 Jul 1;11(4):261-77. [DOI]
7. Joschek HI. Risk assessment in the chemical industry. In: Proceeding of the international topical meeting on probabilistic risk assessmen. New York, NY: American Society of Chemical Engineers. 1981.
8. RG B. Human and organizational factors in safety of engineered systems. In: Conference proceedings for American Society of Safety Engineers Region III and Texas Safety Association. 1998. [Google Scholar]
9. Jahangiri M, Hoboubi N, Rostamabadi A, Keshavarzi S, Hosseini AA. Human error analysis in a permit to work system: a case study in a chemical plant. Saf Health Work. 2016 Mar 1;7(1):6-11. [DOI] [PMID] [PMCID]
10. International, Association, of, Oil, &, Gas, et al. Risk assessment data directory. In: International, Association, of, Oil, &, Gas, et al., editors. Auderghem, Belgium2010.
11. Kirwan B. Human error identification techniques for risk assessment of high risk systems-Part 1: review and evaluation of techniques. Appl. Ergon. 1998 Jun 1;29(3):157-77. [DOI]
12. Johan A, Stanton N. Task Analysis (Hardcover). [Google Scholar]
13. Said MH, Noor MFAM, editors. Technique for the retrospective and predictive analysis of cognitive errors in maritime pilotage operations. 12th international UMT annual symposium" advancements in marine and freshwater sciences; 2013. [Article]
14. Shorrock ST, Kirwan B. Development and application of a human error identification tool for air traffic control. Appl. Ergon. 2002 Jul 1;33(4):319-36. [DOI]
15. Shorrock ST. Errors of perception in air traffic control. Saf. Sci. 2007 Oct 1;45(8):890-904. [DOI]
16. Shorrock ST. Errors of memory in air traffic control. Saf. Sci. 2005 Oct 1;43(8):571-88. [DOI]
17. Theophilus SC, Ekpenyong IE, Ifelebuegu AO, Arewa AO, Agyekum-Mensah G, Ajare TO. A technique for the retrospective and predictive analysis of cognitive errors for the oil and gas industry (TRACEr-OGI). Saf. Sci. 2017 Dec; 3(4):23. [DOI]
18. Baysari MT, Caponecchia C, McIntosh AS. A reliability and usability study of TRACEr-RAV: The technique for the retrospective analysis of cognitive errors-For rail, Australian version. Appl. Ergon. 2011 Nov 1;42(6):852-9. [DOI] [PMID]
19. Shirali G, Hosseinzadeh T, Dibeh Khosravi A, Rasi H, Moradi MS, Karami E, Fathi A, Rezaei M, Barzegar L. Integration of human information processing model and SHERPA technique in the analysis of human errors: A Case Study in the control room for the petrochemical industry. Iran Occup. Health. 2017 Apr 10;14(1):1-1. [Article]
20. Petrillo A, Falcone D, De Felice F, Zomparelli F. Development of a risk analysis model to evaluate human error in industrial plants and in critical infrastructures. Int. J. Disaster Risk Reduct. 2017 Aug 1;23:15-24. [DOI]
21. Ghasemi M, Nasleseraji J, Hoseinabadi S, Zare M. Application of SHERPA to identify and prevent human errors in control units of petrochemical industry. Int J Occup Saf Ergon. 2013 Jan 1;19(2):203-9. [DOI] [PMID]
22. Ghasemi M, Saraji G, Zakerian A, Azhdari MR. Control of human errors and comparison of risk levels after correction action with the SHERPA method in a control room of petrochemical industry. Iran Occup. Health. 2011 Oct 1;8(3). [Google Scholar]
23. Shokria S. A Cognitive Human Error Analysis with CREAM in Control Room of Petrochemical Industry. Biotech. Health. Sci. 2017(1):13-21. [DOI]
24. Maddah S, Ghasemi M. Estimating the human error probability using the fuzzy logic approach of CREAM (The case of a control room in a petrochemical industry). Organization.;4:0-100. [Article]
25. Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human error analysis among petrochemical plant control room operators with human error assessment and reduction technique. Iran Occup. Health. 2009 Jul 25;6(2):38-50. [Article]
26. Sandom C, Harvey RS, editors. Human factors for engineers. Iet; 2004 Aug 13. [DOI]
27. Swain AD, Guttmann HE. Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report. Sandia National Labs.; 1983. [DOI]
28. Isaac A, Shorrock ST, Kirwan B. Human error in European air traffic management: the HERA project. Reliab. Eng. Syst. Saf. 2002 Feb 1;75(2):257-72. [DOI]
29. Cheng CM, Hwang SL. Applications of integrated human error identification techniques on the chemical cylinder change task. Appl. Ergon. 2015 Mar 1;47:274-84. [DOI] [PMID]
30. Abbas Shirali G, Malekzadeh M. Classification and quantification of human error in air traffic control: a case study in an airport control tower. Int J Occup Saf Ergon. 2020 Aug 27:1-3. [DOI] [PMID]
31. Shirali GA, Malekzadeh M. Predictive Analysis of Controllers' Cognitive Errors Using the TRACEr Technique: A Case Study in an Airport Control Tower. Jundishapur. J. Health. Sci. 2016;8(2). [DOI]
32. Orosi M, Mombeni B. Assessment of human errors in paper machines of pars paper industrial group by Predictive Human Error Analysis (PHEA). Jundishapur. J. Health. Sci. 2012 Dec 31;4(4). [Google Scholar]
33. Corver SC, Aneziris ON. The impact of controller support tools in enroute air traffic control on cognitive error modes: A comparative analysis in two operational environments. Saf. Sci. 2015 Jan 1;71:2-15. [DOI]
34. Halvani G, Mehrparvar AH, Shamsi F, Rafieenia R, Khani Mouseloo B, Ebrahimi G. Risk assessment of human error among Mohr City, Parsian Gas refinery company control room operators using systematic human error reduction and prediction approach SHERPA in 2016. Occup Med (Lond). 2017 Jul 10;9(3):32-44. [Article]
35. Jones DG, Endsley MR. Sources of situation awareness errors in aviation. Aviation, space, and environmental medicine. 1996 Jun. [Google Scholar]
36. Lin CJ, Yenn TC, Jou YT, Hsieh TL, Yang CW. Analyzing the staffing and workload in the main control room of the advanced nuclear power plant from the human information processing perspective. Saf. Sci. 2013 Aug 1;57:161-8. [DOI]
37. Shirali G, Dibeh Khosravi A, Hosseinzadeh T, Fathi A, Hame Rezaee M, Hamzeiyan Ziariani M. Using the human information-processing model and workload to predict staffing demand: A case study in a petrochemical control room. Iran J Ergon. 2014 Dec 10;2(3):70-6. [Article]
38. Lane R, Stanton NA, Harrison D. Applying hierarchical task analysis to medication administration errors. Applied ergonomics. 2006 Sep 1;37(5):669-79. [DOI] [PMID]
39. Kirwan B, Scannali S, Robinson L. A case study of a human reliability assessment for an existing nuclear power plant. Appl. Ergon. 1996 Oct 1;27(5):289-302. [DOI]
40. Sikorski M. Use of digital simulation in reliability analysis for the design of industrial process control systems. Reliab. Eng. Syst. Saf. 1991 Jan 1;31(3):281-95. [DOI]
41. Grozdanović M, Stojiljković E. Framework for human error quantification. FU Phil Soc Psy Hist. 2006;5(1):131-44. [Google Scholar]

Add your comments about this article : Your username or Email:
CAPTCHA

Send email to the article author


Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

© 2024 CC BY-NC 4.0 | Iranian Journal of Ergonomics

Designed & Developed by : Yektaweb |