Human Risk Contributions in Process Industry: Guides for Their Pre-Identification in Well-Structured Activities and for Post-Incident Analysis

摘要

The report should be considered a guide for the treating of human errors: for identifying their possibilities of occurrence when designing well-structured human tasks and for their improvement when they occur in reality. For these purposes a strong coupling between predictive and retrospective analysis is emphasized: In order to control human errors, post-incident analysis of cases with human errors in a given industrial plant should be performed as means of feedback from reality for the verification of results of predictive analysis and also as general means of identifying and improving such human errors which cannot be expected covered by predictive analysis. Primarily, the guide addresses people with a knowledge of the technical plant in question and involved in the safety-oriented design and improvement of human activities and without a particular human factors background. The main report describes the procedures for post-incident analysis and for Work Analysis, which is a search strategy developed for well-defined activities, e.g. test and calibration, and constitutes a formalized procedure for the pre-identification of relevant human errors leading to a lack of task result and/or to immediate effects not covered by the lack of task result itself. Work Analysis and the post-incident analysis procedure are based on a common description system for human malfunctions. This system is explained in appendix and so are its underlying models and way of reasoning. Finally, a word index is provided for supporting the reader. (ERA citation 13:008846)