Identification and Analysis of Human Errors in the Maintenance Activities of Molecular Sieve Replacement in the Dehydration Unit of Gas Refineries Using Predictive Human Error Analysis Method

摘要

Introduction: Incidental Events in the maintenance activities in the Dehydration Unit of Gas Refineries due to human error, indicate the inadequate effectiveness of the techniques available to identify human errors. The purpose of this research is to identify and analyze human error in this repair activity using the PHEA predictive human error analysis technique and provide appropriate control strategies to prevent or reduce the consequences of identified errors.Methods: In this technique, all activities and tasks performed to achieve the main goal were identified using the HTA technique, and then possible types of human error in each phases of the above process were predicted and identified by using the PHEA method and using a series of guidance words.After determining the consequences of each of the errors, appropriate control methods were also provided.Results: Out of 11 operations and 111 sub task occupations analyzed in the PHEA worksheets, a total of 337 errors were identified, of which there were 246 action errors, 13 checking errors, 28 retrieval errors, 33 information communication errors and 17 planning errors. The most significant identified errors are Operation omitted, Misalign, Operation incomplete, Operation mistimed, Right operation on wrong object and Operation too little/too much.Conclusion: According to the results, functional errors are the most common abundance that emphasizes the necessity of using control strategies in the form of adequate and effective training for personnel, preparation and modification of instructions, monitoring of implementation of work and hardware changes.