Technique for Human-Error-Sequence Identification and Signification

摘要

The human factor appears to have an important influence on the safety of complex installations, but much less is known about this factor than about the technical factor. This is particularly true in the case of human performance causing an undesired situation (initiating event) during a change in a process state (start-up and shut-down) according to a given procedure. One of the techniques applied to the analysis of technical failures is the event-tree technique. The method is also used to analyze single human errors. The aim of the present study was to investigate whether the event-tree technique can be used for the analysis of sequences of human errors that could cause initiating events. The scope of the study was limited to a consideration of the performance of procedural actions. The main conclusion to be drawn from the study is that, with certain limitations, event trees can be used to predict sequences of human errors if procedural actions are performed. The limitations are related to the nature of the actions performed, the ergonomics of the panel layout, the existence of several procedures to achieve the same goal and the knowledge of all kinds of data.