Human Errors in Decision Making

OpenAIRE

Mohamad, Shahriari; Aliandrina, Dessy; Feng, Yan

2005-01-01

The aim of this paper was to identify human errors in decision making process. The study was focused on a research question such as: what could be the human error as a potential of decision failure in evaluation of the alternatives in the process of decision making. Two case studies were selected from the literature and analyzed to find the human errors contribute to decision fail. Then the analysis of human errors was linked with mental models in evaluation of alternative step. The results o...

The treatment of commission errors in first generation human reliability analysis methods

Energy Technology Data Exchange (ETDEWEB)

Alvarengga, Marco Antonio Bayout; Fonseca, Renato Alves da, E-mail: bayout@cnen.gov.b, E-mail: rfonseca@cnen.gov.b [Comissao Nacional de Energia Nuclear (CNEN) Rio de Janeiro, RJ (Brazil); Melo, Paulo Fernando Frutuoso e, E-mail: frutuoso@nuclear.ufrj.b [Coordenacao dos Programas de Pos-Graduacao de Engenharia (PEN/COPPE/UFRJ), RJ (Brazil). Programa de Engenharia Nuclear

2011-07-01

Human errors in human reliability analysis can be classified generically as errors of omission and commission errors. Omission errors are related to the omission of any human action that should have been performed, but does not occur. Errors of commission are those related to human actions that should not be performed, but which in fact are performed. Both involve specific types of cognitive error mechanisms, however, errors of commission are more difficult to model because they are characterized by non-anticipated actions that are performed instead of others that are omitted (omission errors) or are entered into an operational task without being part of the normal sequence of this task. The identification of actions that are not supposed to occur depends on the operational context that will influence or become easy certain unsafe actions of the operator depending on the operational performance of its parameters and variables. The survey of operational contexts and associated unsafe actions is a characteristic of second-generation models, unlike the first generation models. This paper discusses how first generation models can treat errors of commission in the steps of detection, diagnosis, decision-making and implementation, in the human information processing, particularly with the use of THERP tables of errors quantification. (author)

Trend analysis of human error events and assessment of their proactive prevention measure at Rokkasho reprocessing plant

International Nuclear Information System (INIS)

Yamazaki, Satoru; Tanaka, Izumi; Wakabayashi, Toshio

2012-01-01

A trend analysis of human error events is important for preventing the recurrence of human error events. We propose a new method for identifying the common characteristics from results of trend analysis, such as the latent weakness of organization, and a management process for strategic error prevention. In this paper, we describe a trend analysis method for human error events that have been accumulated in the organization and the utilization of the results of trend analysis to prevent accidents proactively. Although the systematic analysis of human error events, the monitoring of their overall trend, and the utilization of the analyzed results have been examined for the plant operation, such information has never been utilized completely. Sharing information on human error events and analyzing their causes lead to the clarification of problems in the management and human factors. This new method was applied to the human error events that occurred in the Rokkasho reprocessing plant from 2010 October. Results revealed that the output of this method is effective in judging the error prevention plan and that the number of human error events is reduced to about 50% those observed in 2009 and 2010. (author)

Trial application of a technique for human error analysis (ATHEANA)

International Nuclear Information System (INIS)

Bley, D.C.; Cooper, S.E.; Parry, G.W.

1996-01-01

The new method for HRA, ATHEANA, has been developed based on a study of the operating history of serious accidents and an understanding of the reasons why people make errors. Previous publications associated with the project have dealt with the theoretical framework under which errors occur and the retrospective analysis of operational events. This is the first attempt to use ATHEANA in a prospective way, to select and evaluate human errors within the PSA context

Research on Human-Error Factors of Civil Aircraft Pilots Based On Grey Relational Analysis

Directory of Open Access Journals (Sweden)

Guo Yundong

2018-01-01

Full Text Available In consideration of the situation that civil aviation accidents involve many human-error factors and show the features of typical grey systems, an index system of civil aviation accident human-error factors is built using human factor analysis and classification system model. With the data of accidents happened worldwide between 2008 and 2011, the correlation between human-error factors can be analyzed quantitatively using the method of grey relational analysis. Research results show that the order of main factors affecting pilot human-error factors is preconditions for unsafe acts, unsafe supervision, organization and unsafe acts. The factor related most closely with second-level indexes and pilot human-error factors is the physical/mental limitations of pilots, followed by supervisory violations. The relevancy between the first-level indexes and the corresponding second-level indexes and the relevancy between second-level indexes can also be analyzed quantitatively.

A human error analysis methodology, AGAPE-ET, for emergency tasks in nuclear power plants and its application

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Jung, Won Dea [Korea Atomic Energy Research Institute, Taejeon (Korea)

2002-03-01

This report presents a procedurised human reliability analysis (HRA) methodology, AGAPE-ET (A Guidance And Procedure for Human Error Analysis for Emergency Tasks), for both qualitative error analysis and quantification of human error probability (HEP) of emergency tasks in nuclear power plants. The AGAPE-ET is based on the simplified cognitive model. By each cognitive function, error causes or error-likely situations have been identified considering the characteristics of the performance of each cognitive function and influencing mechanism of PIFs on the cognitive function. Then, error analysis items have been determined from the identified error causes or error-likely situations to help the analysts cue or guide overall human error analysis. A human error analysis procedure based on the error analysis items is organised. The basic scheme for the quantification of HEP consists in the multiplication of the BHEP assigned by the error analysis item and the weight from the influencing factors decision tree (IFDT) constituted by cognitive function. The method can be characterised by the structured identification of the weak points of the task required to perform and the efficient analysis process that the analysts have only to carry out with the necessary cognitive functions. The report also presents the the application of AFAPE-ET to 31 nuclear emergency tasks and its results. 42 refs., 7 figs., 36 tabs. (Author)

Application of grey incidence analysis to connection between human errors and root cause

International Nuclear Information System (INIS)

Ren Yinxiang; Yu Ren; Zhou Gang; Chen Dengke

2008-01-01

By introducing grey incidence analysis, the relatively important impact of root cause upon human errors was researched in the paper. On the basis of WANO statistic data and grey incidence analysis, lack of alternate examine, bad basic operation, short of theoretical knowledge, relaxation of organization and management and deficiency of regulations are the important influence of root cause on human err ors. Finally, the question to reduce human errors was discussed. (authors)

Analysis of Human Error Types and Performance Shaping Factors in the Next Generation Main Control Room

International Nuclear Information System (INIS)

Sin, Y. C.; Jung, Y. S.; Kim, K. H.; Kim, J. H.

2008-04-01

Main control room of nuclear power plants has been computerized and digitalized in new and modernized plants, as information and digital technologies make great progresses and become mature. Survey on human factors engineering issues in advanced MCRs: Model-based approach, Literature survey-based approach. Analysis of human error types and performance shaping factors is analysis of three human errors. The results of project can be used for task analysis, evaluation of human error probabilities, and analysis of performance shaping factors in the HRA analysis

A Human Reliability Analysis of Post- Accident Human Errors in the Low Power and Shutdown PSA of KSNP

Energy Technology Data Exchange (ETDEWEB)

Kang, Daeil; Kim, J. H.; Jang, S. C

2007-03-15

Korea Atomic Energy Research Institute, using the ANS low power and shutdown (LPSD) probabilistic risk assessment (PRA) Standard, evaluated the LPSD PSA model of the KSNP, Yonggwang Units 5 and 6, and identified the items to be improved. The evaluation results of human reliability analysis (HRA) of the post-accident human errors in the LPSD PSA model for the KSNP showed that 10 items among 19 items of supporting requirements for those in the ANS PRA Standard were identified as them to be improved. Thus, we newly carried out a HRA for post-accident human errors in the LPSD PSA model for the KSNP. Following tasks are the improvements in the HRA of post-accident human errors of the LPSD PSA model for the KSNP compared with the previous one: Interviews with operators in the interpretation of the procedure, modeling of operator actions, and the quantification results of human errors, site visit. Applications of limiting value to the combined post-accident human errors. Documentation of information of all the input and bases for the detailed quantifications and the dependency analysis using the quantification sheets The assessment results for the new HRA results of post-accident human errors using the ANS LPSD PRA Standard show that above 80% items of its supporting requirements for post-accident human errors were graded as its Category II. The number of the re-estimated human errors using the LPSD Korea Standard HRA method is 385. Among them, the number of individual post-accident human errors is 253. The number of dependent post-accident human errors is 135. The quantification results of the LPSD PSA model for the KSNP with new HEPs show that core damage frequency (CDF) is increased by 5.1% compared with the previous baseline CDF It is expected that this study results will be greatly helpful to improve the PSA quality for the domestic nuclear power plants because they have sufficient PSA quality to meet the Category II of Supporting Requirements for the post

A Human Reliability Analysis of Post- Accident Human Errors in the Low Power and Shutdown PSA of KSNP

International Nuclear Information System (INIS)

Kang, Daeil; Kim, J. H.; Jang, S. C.

2007-03-01

Korea Atomic Energy Research Institute, using the ANS low power and shutdown (LPSD) probabilistic risk assessment (PRA) Standard, evaluated the LPSD PSA model of the KSNP, Yonggwang Units 5 and 6, and identified the items to be improved. The evaluation results of human reliability analysis (HRA) of the post-accident human errors in the LPSD PSA model for the KSNP showed that 10 items among 19 items of supporting requirements for those in the ANS PRA Standard were identified as them to be improved. Thus, we newly carried out a HRA for post-accident human errors in the LPSD PSA model for the KSNP. Following tasks are the improvements in the HRA of post-accident human errors of the LPSD PSA model for the KSNP compared with the previous one: Interviews with operators in the interpretation of the procedure, modeling of operator actions, and the quantification results of human errors, site visit. Applications of limiting value to the combined post-accident human errors. Documentation of information of all the input and bases for the detailed quantifications and the dependency analysis using the quantification sheets The assessment results for the new HRA results of post-accident human errors using the ANS LPSD PRA Standard show that above 80% items of its supporting requirements for post-accident human errors were graded as its Category II. The number of the re-estimated human errors using the LPSD Korea Standard HRA method is 385. Among them, the number of individual post-accident human errors is 253. The number of dependent post-accident human errors is 135. The quantification results of the LPSD PSA model for the KSNP with new HEPs show that core damage frequency (CDF) is increased by 5.1% compared with the previous baseline CDF It is expected that this study results will be greatly helpful to improve the PSA quality for the domestic nuclear power plants because they have sufficient PSA quality to meet the Category II of Supporting Requirements for the post

A Human Error Analysis with Physiological Signals during Utilizing Digital Devices

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Oh, Yeon Ju; Shin, Kwang Hyeon [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2011-10-15

The introduction of advanced MCR is accompanied with lots of changes and different forms and features through the virtue of new digital technologies. There are various kinds of digital devices such as flat panel displays, touch screens, and so on. The characteristics of these digital devices give many chances to the interface management, and can be integrated into a compact single workstation in an advanced MCR so that workers can operate the plant with minimum burden during any operating condition. However, these devices may introduce new types of human errors, and thus we need a means to evaluate and prevent such error, especially those related to the digital devices. Human errors have been retrospectively assessed for accident reviews and quantitatively evaluated through HRA for PSA. However, the ergonomic verification and validation is an important process to defend all human error potential in the NPP design. HRA is a crucial part of a PSA, and helps in preparing a countermeasure for design by drawing potential human error items that affect the overall safety of NPPs. Various HRA techniques are available however: they reveal shortages of the HMI design in the digital era. - HRA techniques depend on PSFs: this means that the scope dealing with human factors is previously limited, and thus all attributes of new digital devices may not be considered in HRA. - The data used to HRA are not close to the evaluation items. So, human error analysis is not easy to apply to design by several individual experiments and cases. - The results of HRA are not statistically meaningful because accidents including human errors in NPPs are rare and have been estimated as having an extremely low probability

A technique for human error analysis (ATHEANA)

International Nuclear Information System (INIS)

Cooper, S.E.; Ramey-Smith, A.M.; Wreathall, J.; Parry, G.W.

1996-05-01

Probabilistic risk assessment (PRA) has become an important tool in the nuclear power industry, both for the Nuclear Regulatory Commission (NRC) and the operating utilities. Human reliability analysis (HRA) is a critical element of PRA; however, limitations in the analysis of human actions in PRAs have long been recognized as a constraint when using PRA. A multidisciplinary HRA framework has been developed with the objective of providing a structured approach for analyzing operating experience and understanding nuclear plant safety, human error, and the underlying factors that affect them. The concepts of the framework have matured into a rudimentary working HRA method. A trial application of the method has demonstrated that it is possible to identify potentially significant human failure events from actual operating experience which are not generally included in current PRAs, as well as to identify associated performance shaping factors and plant conditions that have an observable impact on the frequency of core damage. A general process was developed, albeit in preliminary form, that addresses the iterative steps of defining human failure events and estimating their probabilities using search schemes. Additionally, a knowledge- base was developed which describes the links between performance shaping factors and resulting unsafe actions

A technique for human error analysis (ATHEANA)

Energy Technology Data Exchange (ETDEWEB)

Cooper, S.E.; Ramey-Smith, A.M.; Wreathall, J.; Parry, G.W. [and others

1996-05-01

Probabilistic risk assessment (PRA) has become an important tool in the nuclear power industry, both for the Nuclear Regulatory Commission (NRC) and the operating utilities. Human reliability analysis (HRA) is a critical element of PRA; however, limitations in the analysis of human actions in PRAs have long been recognized as a constraint when using PRA. A multidisciplinary HRA framework has been developed with the objective of providing a structured approach for analyzing operating experience and understanding nuclear plant safety, human error, and the underlying factors that affect them. The concepts of the framework have matured into a rudimentary working HRA method. A trial application of the method has demonstrated that it is possible to identify potentially significant human failure events from actual operating experience which are not generally included in current PRAs, as well as to identify associated performance shaping factors and plant conditions that have an observable impact on the frequency of core damage. A general process was developed, albeit in preliminary form, that addresses the iterative steps of defining human failure events and estimating their probabilities using search schemes. Additionally, a knowledge- base was developed which describes the links between performance shaping factors and resulting unsafe actions.

Human errors in NPP operations

International Nuclear Information System (INIS)

Sheng Jufang

1993-01-01

Based on the operational experiences of nuclear power plants (NPPs), the importance of studying human performance problems is described. Statistical analysis on the significance or frequency of various root-causes and error-modes from a large number of human-error-related events demonstrate that the defects in operation/maintenance procedures, working place factors, communication and training practices are primary root-causes, while omission, transposition, quantitative mistake are the most frequent among the error-modes. Recommendations about domestic research on human performance problem in NPPs are suggested

Application of human error theory in case analysis of wrong procedures.

Science.gov (United States)

Duthie, Elizabeth A

2010-06-01

The goal of this study was to contribute to the emerging body of literature about the role of human behaviors and cognitive processes in the commission of wrong procedures. Case analysis of 5 wrong procedures in operative and nonoperative settings using James Reason's human error theory was performed. The case analysis showed that cognitive underspecification, cognitive flips, automode processing, and skill-based errors were contributory to wrong procedures. Wrong-site procedures accounted for the preponderance of the cases. Front-line supervisory staff used corrective actions that focused on the performance of the individual without taking into account cognitive factors. System fixes using human cognition concepts have a greater chance of achieving sustainable safety outcomes than those that are based on the traditional approach of counseling, education, and disciplinary action for staff.

Analysis of Human Errors in Japanese Nuclear Power Plants using JHPES/JAESS

International Nuclear Information System (INIS)

Kojima, Mitsuhiro; Mimura, Masahiro; Yamaguchi, Osamu

1998-01-01

CRIEPI (Central Research Institute for Electric Power Industries) / HFC (Human Factors research Center) developed J-HPES (Japanese version of Human Performance Enhancement System) based on the HPES which was originally developed by INPO to analyze events resulted from human errors. J-HPES was systematized into a computer program named JAESS (J-HPES Analysis and Evaluation Support System) and both systems were distributed to all Japanese electric power companies to analyze events by themselves. CRIEPI / HFC also analyzed the incidents in Japanese nuclear power plants (NPPs) which were officially reported and identified as human error related with J-HPES / JAESS. These incidents have numbered up to 188 cases over the last 30 years. An outline of this analysis is given, and some preliminary findings are shown. (authors)

Human reliability analysis during PSA at Trillo NPP: main characteristics and analysis of diagnostic errors

International Nuclear Information System (INIS)

Barquin, M.A.; Gomez, F.

1998-01-01

The design difference between Trillo NPP and other Spanish nuclear power plants (basic Westinghouse and General Electric designs) were made clear in the Human Reliability Analysis of the Probabilistic Safety Analysis (PSA) for Trillo NPP. The object of this paper is to describe the most significant characteristics of the Human Reliability Analysis carried out in the PSA, with special emphasis on the possible diagnostic errors and their consequences, based on the characteristics in the Emergency Operations Manual for Trillo NPP. - In the case of human errors before the initiating event (type 1), the existence of four redundancies in most of the plant safety systems, means that the impact of this type or error on the final results of the PSA is insignificant. However, in the case common cause errors, especially in certain calibration errors, some actions are significant in the final equation for core damage - The number of human actions that the operator has to carry out during the accidents (type 3) modelled, is relatively small in comparison with this value in other PSAs. This is basically due to the high level of automation at Rillo NPP - The Plant Operations Manual cannot be strictly considered to be a symptoms-based procedure. The operation Group must select the chapter from the Operations Manual to be followed, after having diagnosed the perturbing event, using for this purpose and Emergency and Anomaly Decision Tree (M.O.3.0.1) based on the different indications, alarms and symptoms present in the plant after the perturbing event. For this reason, it was decided to analyse the possible diagnosis errors. In the bibliography on diagnosis and commission errors available at the present time, there is no precise methodology for the analysis of this type of error and its incorporation into PSAs. The method used in the PSA for Trillo y NPP to evaluate this type of interaction, is to develop a Diagnosis Error Table, the object of which is to identify the situations in

Understanding human management of automation errors

Science.gov (United States)

McBride, Sara E.; Rogers, Wendy A.; Fisk, Arthur D.

2013-01-01

Automation has the potential to aid humans with a diverse set of tasks and support overall system performance. Automated systems are not always reliable, and when automation errs, humans must engage in error management, which is the process of detecting, understanding, and correcting errors. However, this process of error management in the context of human-automation interaction is not well understood. Therefore, we conducted a systematic review of the variables that contribute to error management. We examined relevant research in human-automation interaction and human error to identify critical automation, person, task, and emergent variables. We propose a framework for management of automation errors to incorporate and build upon previous models. Further, our analysis highlights variables that may be addressed through design and training to positively influence error management. Additional efforts to understand the error management process will contribute to automation designed and implemented to support safe and effective system performance. PMID:25383042

A qualitative description of human error

International Nuclear Information System (INIS)

Li Zhaohuan

1992-11-01

The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed

A qualitative description of human error

Energy Technology Data Exchange (ETDEWEB)

Zhaohuan, Li [Academia Sinica, Beijing, BJ (China). Inst. of Atomic Energy

1992-11-01

The human error has an important contribution to risk of reactor operation. The insight and analytical model are main parts in human reliability analysis. It consists of the concept of human error, the nature, the mechanism of generation, the classification and human performance influence factors. On the operating reactor the human error is defined as the task-human-machine mismatch. The human error event is focused on the erroneous action and the unfavored result. From the time limitation of performing a task, the operation is divided into time-limited and time-opened. The HCR (human cognitive reliability) model is suited for only time-limited. The basic cognitive process consists of the information gathering, cognition/thinking, decision making and action. The human erroneous action may be generated in any stage of this process. The more natural ways to classify human errors are presented. The human performance influence factors including personal, organizational and environmental factors are also listed.

PRA (probabilistic risk analysis) in the nuclear sector. Quantifying human error and human malice

International Nuclear Information System (INIS)

Heyes, A.G.

1995-01-01

Regardless of the regulatory style chosen ('command and control' or 'functional') a vital prerequisite for coherent safety regulations in the nuclear power industry is the ability to assess accident risk. In this paper we present a critical analysis of current techniques of probabilistic risk analysis applied in the industry, with particular regard to the problems of quantifying risks arising from, or exacerbated by, human risk and/or human error. (Author)

Interactive analysis of human error factors in NPP operation events

International Nuclear Information System (INIS)

Zhang Li; Zou Yanhua; Huang Weigang

2010-01-01

Interactive of human error factors in NPP operation events were introduced, and 645 WANO operation event reports from 1999 to 2008 were analyzed, among which 432 were found relative to human errors. After classifying these errors with the Root Causes or Causal Factors, and then applying SPSS for correlation analysis,we concluded: (1) Personnel work practices are restricted by many factors. Forming a good personnel work practices is a systematic work which need supports in many aspects. (2)Verbal communications,personnel work practices, man-machine interface and written procedures and documents play great roles. They are four interaction factors which often come in bundle. If some improvements need to be made on one of them,synchronous measures are also necessary for the others.(3) Management direction and decision process, which are related to management,have a significant interaction with personnel factors. (authors)

Detailed semantic analyses of human error incidents occurring at nuclear power plants. Extraction of periodical transition of error occurrence patterns by applying multivariate analysis

International Nuclear Information System (INIS)

Hirotsu, Yuko; Suzuki, Kunihiko; Takano, Kenichi; Kojima, Mitsuhiro

2000-01-01

It is essential for preventing the recurrence of human error incidents to analyze and evaluate them with the emphasis on human factor. Detailed and structured analyses of all incidents at domestic nuclear power plants (NPPs) reported during last 31 years have been conducted based on J-HPES, in which total 193 human error cases are identified. Results obtained by the analyses have been stored into the J-HPES database. In the previous study, by applying multivariate analysis to above case studies, it was suggested that there were several occurrence patterns identified of how errors occur at NPPs. It was also clarified that the causes related to each human error are different depending on age of their occurrence. This paper described the obtained results in respects of periodical transition of human error occurrence patterns. By applying multivariate analysis to the above data, it was suggested there were two types of error occurrence patterns as to each human error type. First type is common occurrence patterns, not depending on the age, and second type is the one influenced by periodical characteristics. (author)

A Conceptual Framework of Human Reliability Analysis for Execution Human Error in NPP Advanced MCRs

Energy Technology Data Exchange (ETDEWEB)

Jang, In Seok; Kim, Ar Ryum; Seong, Poong Hyun [KAIST, Daejeon (Korea, Republic of); Jung, Won Dea [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2014-08-15

The operation environment of Main Control Rooms (MCRs) in Nuclear Power Plants (NPPs) has changed with the adoption of new human-system interfaces that are based on computer-based technologies. The MCRs that include these digital and computer technologies, such as large display panels, computerized procedures, and soft controls, are called Advanced MCRs. Among the many features of Advanced MCRs, soft controls are a particularly important feature because the operation action in NPP Advanced MCRs is performed by soft control. Using soft controls such as mouse control, and touch screens, operators can select a specific screen, then choose the controller, and finally manipulate the given devices. Due to the different interfaces between soft control and hardwired conventional type control, different human error probabilities and a new Human Reliability Analysis (HRA) framework should be considered in the HRA for advanced MCRs. In other words, new human error modes should be considered for interface management tasks such as navigation tasks, and icon (device) selection tasks in monitors and a new framework of HRA method taking these newly generated human error modes into account should be considered. In this paper, a conceptual framework for a HRA method for the evaluation of soft control execution human error in advanced MCRs is suggested by analyzing soft control tasks.

A Conceptual Framework of Human Reliability Analysis for Execution Human Error in NPP Advanced MCRs

International Nuclear Information System (INIS)

Jang, In Seok; Kim, Ar Ryum; Seong, Poong Hyun; Jung, Won Dea

2014-01-01

The operation environment of Main Control Rooms (MCRs) in Nuclear Power Plants (NPPs) has changed with the adoption of new human-system interfaces that are based on computer-based technologies. The MCRs that include these digital and computer technologies, such as large display panels, computerized procedures, and soft controls, are called Advanced MCRs. Among the many features of Advanced MCRs, soft controls are a particularly important feature because the operation action in NPP Advanced MCRs is performed by soft control. Using soft controls such as mouse control, and touch screens, operators can select a specific screen, then choose the controller, and finally manipulate the given devices. Due to the different interfaces between soft control and hardwired conventional type control, different human error probabilities and a new Human Reliability Analysis (HRA) framework should be considered in the HRA for advanced MCRs. In other words, new human error modes should be considered for interface management tasks such as navigation tasks, and icon (device) selection tasks in monitors and a new framework of HRA method taking these newly generated human error modes into account should be considered. In this paper, a conceptual framework for a HRA method for the evaluation of soft control execution human error in advanced MCRs is suggested by analyzing soft control tasks

A methodology for collection and analysis of human error data based on a cognitive model: IDA

International Nuclear Information System (INIS)

Shen, S.-H.; Smidts, C.; Mosleh, A.

1997-01-01

This paper presents a model-based human error taxonomy and data collection. The underlying model, IDA (described in two companion papers), is a cognitive model of behavior developed for analysis of the actions of nuclear power plant operating crew during abnormal situations. The taxonomy is established with reference to three external reference points (i.e. plant status, procedures, and crew) and four reference points internal to the model (i.e. information collected, diagnosis, decision, action). The taxonomy helps the analyst: (1) recognize errors as such; (2) categorize the error in terms of generic characteristics such as 'error in selection of problem solving strategies' and (3) identify the root causes of the error. The data collection methodology is summarized in post event operator interview and analysis summary forms. The root cause analysis methodology is illustrated using a subset of an actual event. Statistics, which extract generic characteristics of error prone behaviors and error prone situations are presented. Finally, applications of the human error data collection are reviewed. A primary benefit of this methodology is to define better symptom-based and other auxiliary procedures with associated training to minimize or preclude certain human errors. It also helps in design of control rooms, and in assessment of human error probabilities in the probabilistic risk assessment framework. (orig.)

Game Design Principles based on Human Error

Directory of Open Access Journals (Sweden)

Guilherme Zaffari

2016-03-01

Full Text Available This paper displays the result of the authors’ research regarding to the incorporation of Human Error, through design principles, to video game design. In a general way, designers must consider Human Error factors throughout video game interface development; however, when related to its core design, adaptations are in need, since challenge is an important factor for fun and under the perspective of Human Error, challenge can be considered as a flaw in the system. The research utilized Human Error classifications, data triangulation via predictive human error analysis, and the expanded flow theory to allow the design of a set of principles in order to match the design of playful challenges with the principles of Human Error. From the results, it was possible to conclude that the application of Human Error in game design has a positive effect on player experience, allowing it to interact only with errors associated with the intended aesthetics of the game.

The application of two recently developed human reliability techniques to cognitive error analysis

International Nuclear Information System (INIS)

Gall, W.

1990-01-01

Cognitive error can lead to catastrophic consequences for manned systems, including those whose design renders them immune to the effects of physical slips made by operators. Four such events, pressurized water and boiling water reactor accidents which occurred recently, were analysed. The analysis identifies the factors which contributed to the errors and suggests practical strategies for error recovery or prevention. Two types of analysis were conducted: an unstructured analysis based on the analyst's knowledge of psychological theory, and a structured analysis using two recently-developed human reliability analysis techniques. In general, the structured techniques required less effort to produce results and these were comparable to those of the unstructured analysis. (author)

A human error taxonomy and its application to an automatic method accident analysis

International Nuclear Information System (INIS)

Matthews, R.H.; Winter, P.W.

1983-01-01

Commentary is provided on the quantification aspects of human factors analysis in risk assessment. Methods for quantifying human error in a plant environment are discussed and their application to system quantification explored. Such a programme entails consideration of the data base and a taxonomy of factors contributing to human error. A multi-levelled approach to system quantification is proposed, each level being treated differently drawing on the advantages of different techniques within the fault/event tree framework. Management, as controller of organization, planning and procedure, is assigned a dominant role. (author)

A model-based and computer-aided approach to analysis of human errors in nuclear power plants

International Nuclear Information System (INIS)

Yoon, Wan C.; Lee, Yong H.; Kim, Young S.

1996-01-01

Since the operator's mission in NPPs is increasingly defined by cognitive tasks such as monitoring, diagnosis and planning, the focus of human error analysis should also move from external actions to internal decision-making processes. While more elaborate analysis of cognitive aspects of human errors will help understand their causes and derive effective countermeasures, a lack of framework and an arbitrary resolution of description may hamper the effectiveness of such analysis. This paper presents new model-based schemes of event description and error classification as well as an interactive computerized support system. The schemes and the support system were produced in an effort to develop an improved version of HPES. The use of a decision-making model enables the analyst to document cognitive aspects of human performance explicitly and in a proper resolution. The stage-specific terms used in the proposed schemes make the task of characterizing human errors easier and confident for field analysts. The support system was designed to help the analyst achieve a contextually well-integrated analysis throughout the different parts of HPES

Development of an analysis rule of diagnosis error for standard method of human reliability analysis

International Nuclear Information System (INIS)

Jeong, W. D.; Kang, D. I.; Jeong, K. S.

2003-01-01

This paper presents the status of development of Korea standard method for Human Reliability Analysis (HRA), and proposed a standard procedure and rules for the evaluation of diagnosis error probability. The quality of KSNP HRA was evaluated using the requirement of ASME PRA standard guideline, and the design requirement for the standard HRA method was defined. Analysis procedure and rules, developed so far, to analyze diagnosis error probability was suggested as a part of the standard method. And also a study of comprehensive application was performed to evaluate the suitability of the proposed rules

Human errors identification using the human factors analysis and classification system technique (HFACS

Directory of Open Access Journals (Sweden)

G. A. Shirali

2013-12-01

.Result: In this study, 158 reports of accident in Ahvaz steel industry were analyzed by HFACS technique. This analysis showed that most of the human errors were: in the first level was related to the skill-based errors, in the second to the physical environment, in the third level to the inadequate supervision and in the fourth level to the management of resources. .Conclusion: Studying and analyzing of past events using the HFACS technique can identify the major and root causes of accidents and can be effective on prevent repetitions of such mishaps. Also, it can be used as a basis for developing strategies to prevent future events in steel industries.

Human Errors - A Taxonomy for Describing Human Malfunction in Industrial Installations

DEFF Research Database (Denmark)

Rasmussen, Jens

1982-01-01

This paper describes the definition and the characteristics of human errors. Different types of human behavior are classified, and their relation to different error mechanisms are analyzed. The effect of conditioning factors related to affective, motivating aspects of the work situation as well...... as physiological factors are also taken into consideration. The taxonomy for event analysis, including human malfunction, is presented. Possibilities for the prediction of human error are discussed. The need for careful studies in actual work situations is expressed. Such studies could provide a better...

Human errors related to maintenance and modifications

International Nuclear Information System (INIS)

Laakso, K.; Pyy, P.; Reiman, L.

1998-01-01

The focus in human reliability analysis (HRA) relating to nuclear power plants has traditionally been on human performance in disturbance conditions. On the other hand, some studies and incidents have shown that also maintenance errors, which have taken place earlier in plant history, may have an impact on the severity of a disturbance, e.g. if they disable safety related equipment. Especially common cause and other dependent failures of safety systems may significantly contribute to the core damage risk. The first aim of the study was to identify and give examples of multiple human errors which have penetrated the various error detection and inspection processes of plant safety barriers. Another objective was to generate numerical safety indicators to describe and forecast the effectiveness of maintenance. A more general objective was to identify needs for further development of maintenance quality and planning. In the first phase of this operational experience feedback analysis, human errors recognisable in connection with maintenance were looked for by reviewing about 4400 failure and repair reports and some special reports which cover two nuclear power plant units on the same site during 1992-94. A special effort was made to study dependent human errors since they are generally the most serious ones. An in-depth root cause analysis was made for 14 dependent errors by interviewing plant maintenance foremen and by thoroughly analysing the errors. A more simple treatment was given to maintenance-related single errors. The results were shown as a distribution of errors among operating states i.a. as regards the following matters: in what operational state the errors were committed and detected; in what operational and working condition the errors were detected, and what component and error type they were related to. These results were presented separately for single and dependent maintenance-related errors. As regards dependent errors, observations were also made

A trend analysis of human error events for proactive prevention of accidents. Methodology development and effective utilization

International Nuclear Information System (INIS)

Hirotsu, Yuko; Ebisu, Mitsuhiro; Aikawa, Takeshi; Matsubara, Katsuyuki

2006-01-01

This paper described methods for analyzing human error events that has been accumulated in the individual plant and for utilizing the result to prevent accidents proactively. Firstly, a categorization framework of trigger action and causal factors of human error events were reexamined, and the procedure to analyze human error events was reviewed based on the framework. Secondly, a method for identifying the common characteristics of trigger action data and of causal factor data accumulated by analyzing human error events was clarified. In addition, to utilize the results of trend analysis effectively, methods to develop teaching material for safety education, to develop the checkpoints for the error prevention and to introduce an error management process for strategic error prevention were proposed. (author)

Human errors and mistakes

International Nuclear Information System (INIS)

Wahlstroem, B.

1993-01-01

Human errors have a major contribution to the risks for industrial accidents. Accidents have provided important lesson making it possible to build safer systems. In avoiding human errors it is necessary to adapt the systems to their operators. The complexity of modern industrial systems is however increasing the danger of system accidents. Models of the human operator have been proposed, but the models are not able to give accurate predictions of human performance. Human errors can never be eliminated, but their frequency can be decreased by systematic efforts. The paper gives a brief summary of research in human error and it concludes with suggestions for further work. (orig.)

PERANCANGAN COMPUTER AIDED SYSTEM DALAM MENGANALISA HUMAN ERROR DI PERKERETAAPIAN INDONESIA

Directory of Open Access Journals (Sweden)

Wiwik Budiawan

2013-06-01

Full Text Available Kecelakaan kereta api (KA yang terjadi secara beruntun di Indonesia sudah berada pada tingkat kritis. Berdasarkan data dari Direktorat Jendral Perkeretaapian, dalam kurun 5 tahun terakhir (2005-2009 total terdapat 611 kecelakaan KA.  Banyak faktor yang berkontribusi menyebabkan terjadinya kecelakaan, antara lain: sarana, prasarana, SDM operator (human error, eksternal, dan alam.  Kegagalan manusia (Human error merupakan salah satu faktor yang berpotensi menyebabkan terjadinya suatu kecelakaan KA dan dinyatakan sebagai faktor utama penyebab terjadinya suatu kecelakaan kereta api di Indonesia. Namun, tidak jelas bagaimana teknik analisis ini dilakukan. Kajian human error yang dilakukan Komite Nasional Keselamatan Transportasi (KNKT masih relatif terbatas, tidak dilengkapi dengan metode yang sistematis. Terdapat beberapa metode yang telah dikembangkan saat ini, tetapi untuk moda transportasi kereta api masih belum banyak dikembangkan. Human Factors Analysis and Classification System (HFACS merupakan metode analisis human error yang dikembangkan dan disesuaikan dengan sistem perkeretaapian Indonesia. Guna meningkatkan keandalan dalam analisis human error, HFACS kemudian dikembangkan dalam bentuk aplikasi berbasis web yang dapat diakses di komputer maupun smartphone. Hasil penelitian ini dapat dimanfaatkan oleh KNKT sebagai metode analisis kecelakaan kereta api khususnya terkait dengan human error. Kata kunci : human error, HFACS, CAS, kereta api   Abstract Train wreck (KA which occurred in quick succession in Indonesia already at a critical level. Based on data from the Directorate General of Railways, during the last 5 years (2005-2009 there were a total of 611 railway accidents. Many factors contribute to cause accidents, such as: facilities, infrastructure, human operator (human error, external, and natural. Human failure (Human error is one of the factors that could potentially cause a train accident and expressed as the main factors causing

Human reliability data, human error and accident models--illustration through the Three Mile Island accident analysis

International Nuclear Information System (INIS)

Le Bot, Pierre

2004-01-01

Our first objective is to provide a panorama of Human Reliability data used in EDF's Safety Probabilistic Studies, and then, since these concepts are at the heart of Human Reliability and its methods, to go over the notion of human error and the understanding of accidents. We are not sure today that it is actually possible to provide in this field a foolproof and productive theoretical framework. Consequently, the aim of this article is to suggest potential paths of action and to provide information on EDF's progress along those paths which enables us to produce the most potentially useful Human Reliability analyses while taking into account current knowledge in Human Sciences. The second part of this article illustrates our point of view as EDF researchers through the analysis of the most famous civil nuclear accident, the Three Mile Island unit accident in 1979. Analysis of this accident allowed us to validate our positions regarding the need to move, in the case of an accident, from the concept of human error to that of systemic failure in the operation of systems such as a nuclear power plant. These concepts rely heavily on the notion of distributed cognition and we will explain how we applied it. These concepts were implemented in the MERMOS Human Reliability Probabilistic Assessment methods used in the latest EDF Probabilistic Human Reliability Assessment. Besides the fact that it is not very productive to focus exclusively on individual psychological error, the design of the MERMOS method and its implementation have confirmed two things: the significance of qualitative data collection for Human Reliability, and the central role held by Human Reliability experts in building knowledge about emergency operation, which in effect consists of Human Reliability data collection. The latest conclusion derived from the implementation of MERMOS is that, considering the difficulty in building 'generic' Human Reliability data in the field we are involved in, the best

Technique for human-error sequence identification and signification

International Nuclear Information System (INIS)

Heslinga, G.

1988-01-01

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 event-tree technique was modified to adapt it for this study and will be referred to as the 'Technique for Human-Error-Sequence Identification and Signification' (THESIS). The event trees used in this manner, i.e. THESIS event trees, appear to present additional problems if they are applied to human performance instead of technical systems. These problems, referred to as the 'Man-Related Features' of THESIS, are: the human capability to choose among several procedures, the ergonomics of the panel layout, human actions of a continuous nature, dependence between human errors, human capability to recover possible errors, the influence of memory during the recovery attempt, variability in human performance and correlations between human;erropr probabilities. The influence of these problems on the applicability of THESIS was assessed by means of mathematical analysis, field studies and laboratory experiments (author). 130 refs.; 51 figs.; 24 tabs

Simulator data on human error probabilities

International Nuclear Information System (INIS)

Kozinsky, E.J.; Guttmann, H.E.

1982-01-01

Analysis of operator errors on NPP simulators is being used to determine Human Error Probabilities (HEP) for task elements defined in NUREG/CR 1278. Simulator data tapes from research conducted by EPRI and ORNL are being analyzed for operator error rates. The tapes collected, using Performance Measurement System software developed for EPRI, contain a history of all operator manipulations during simulated casualties. Analysis yields a time history or Operational Sequence Diagram and a manipulation summary, both stored in computer data files. Data searches yield information on operator errors of omission and commission. This work experimentally determines HEPs for Probabilistic Risk Assessment calculations. It is the only practical experimental source of this data to date

Simulator data on human error probabilities

International Nuclear Information System (INIS)

Kozinsky, E.J.; Guttmann, H.E.

1981-01-01

Analysis of operator errors on NPP simulators is being used to determine Human Error Probabilities (HEP) for task elements defined in NUREG/CR-1278. Simulator data tapes from research conducted by EPRI and ORNL are being analyzed for operator error rates. The tapes collected, using Performance Measurement System software developed for EPRI, contain a history of all operator manipulations during simulated casualties. Analysis yields a time history or Operational Sequence Diagram and a manipulation summary, both stored in computer data files. Data searches yield information on operator errors of omission and commission. This work experimentally determined HEP's for Probabilistic Risk Assessment calculations. It is the only practical experimental source of this data to date

Effects of human errors on the determination of surveillance test interval

International Nuclear Information System (INIS)

Chung, Dae Wook; Koo, Bon Hyun

1990-01-01

This paper incorporates the effects of human error relevant to the periodic test on the unavailability of the safety system as well as the component unavailability. Two types of possible human error during the test are considered. One is the possibility that a good safety system is inadvertently left in a bad state after the test (Type A human error) and the other is the possibility that bad safety system is undetected upon the test (Type B human error). An event tree model is developed for the steady-state unavailability of safety system to determine the effects of human errors on the component unavailability and the test interval. We perform the reliability analysis of safety injection system (SIS) by applying aforementioned two types of human error to safety injection pumps. Results of various sensitivity analyses show that; 1) the appropriate test interval decreases and steady-state unavailability increases as the probabilities of both types of human errors increase, and they are far more sensitive to Type A human error than Type B and 2) the SIS unavailability increases slightly as the probability of Type B human error increases, and significantly as the probability of Type A human error increases. Therefore, to avoid underestimation, the effects of human error should be incorporated in the system reliability analysis which aims at the relaxations of the surveillance test intervals, and Type A human error has more important effect on the unavailability and surveillance test interval

SCHEME (Soft Control Human error Evaluation MEthod) for advanced MCR HRA

International Nuclear Information System (INIS)

Jang, Inseok; Jung, Wondea; Seong, Poong Hyun

2015-01-01

The Technique for Human Error Rate Prediction (THERP), Korean Human Reliability Analysis (K-HRA), Human Error Assessment and Reduction Technique (HEART), A Technique for Human Event Analysis (ATHEANA), Cognitive Reliability and Error Analysis Method (CREAM), and Simplified Plant Analysis Risk Human Reliability Assessment (SPAR-H) in relation to NPP maintenance and operation. Most of these methods were developed considering the conventional type of Main Control Rooms (MCRs). They are still used for HRA in advanced MCRs even though the operating environment of advanced MCRs in NPPs has been considerably changed by the adoption of new human-system interfaces such as computer-based soft controls. Among the many features in advanced MCRs, soft controls are an important feature because the operation action in NPP advanced MCRs is performed by soft controls. Consequently, those conventional methods may not sufficiently consider the features of soft control execution human errors. To this end, a new framework of a HRA method for evaluating soft control execution human error is suggested by performing the soft control task analysis and the literature reviews regarding widely accepted human error taxonomies. In this study, the framework of a HRA method for evaluating soft control execution human error in advanced MCRs is developed. First, the factors which HRA method in advanced MCRs should encompass are derived based on the literature review, and soft control task analysis. Based on the derived factors, execution HRA framework in advanced MCRs is developed mainly focusing on the features of soft control. Moreover, since most current HRA database deal with operation in conventional type of MCRs and are not explicitly designed to deal with digital HSI, HRA database are developed under lab scale simulation

Human error mechanisms in complex work environments

International Nuclear Information System (INIS)

Rasmussen, J.

1988-01-01

Human error taxonomies have been developed from analysis of industrial incident reports as well as from psychological experiments. In this paper the results of the two approaches are reviewed and compared. It is found, in both cases, that a fairly small number of basic psychological mechanisms will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations. The implications for system safety and briefly mentioned, together with the implications for system design. (author)

Human error mechanisms in complex work environments

International Nuclear Information System (INIS)

Rasmussen, Jens; Danmarks Tekniske Hoejskole, Copenhagen)

1988-01-01

Human error taxonomies have been developed from analysis of industrial incident reports as well as from psychological experiments. In this paper the results of the two approaches are reviewed and compared. It is found, in both cases, that a fairly small number of basic psychological mechanisms will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations. The implications for system safety are briefly mentioned, together with the implications for system design. (author)

Systematic Analysis of Video Data from Different Human-Robot Interaction Studies: A Categorisation of Social Signals During Error Situations

OpenAIRE

Manuel eGiuliani; Nicole eMirnig; Gerald eStollnberger; Susanne eStadler; Roland eBuchner; Manfred eTscheligi

2015-01-01

Human?robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human?robot interaction experiments. For that, we analyzed 201 videos of five human?robot interaction user studies with varying tasks from four independent projects. The analysis shows tha...

The cost of human error intervention

International Nuclear Information System (INIS)

Bennett, C.T.; Banks, W.W.; Jones, E.D.

1994-03-01

DOE has directed that cost-benefit analyses be conducted as part of the review process for all new DOE orders. This new policy will have the effect of ensuring that DOE analysts can justify the implementation costs of the orders that they develop. We would like to argue that a cost-benefit analysis is merely one phase of a complete risk management program -- one that would more than likely start with a probabilistic risk assessment. The safety community defines risk as the probability of failure times the severity of consequence. An engineering definition of failure can be considered in terms of physical performance, as in mean-time-between-failure; or, it can be thought of in terms of human performance, as in probability of human error. The severity of consequence of a failure can be measured along any one of a number of dimensions -- economic, political, or social. Clearly, an analysis along one dimension cannot be directly compared to another but, a set of cost-benefit analyses, based on a series of cost-dimensions, can be extremely useful to managers who must prioritize their resources. Over the last two years, DOE has been developing a series of human factors orders, directed a lowering the probability of human error -- or at least changing the distribution of those errors. The following discussion presents a series of cost-benefit analyses using historical events in the nuclear industry. However, we would first like to discuss some of the analytic cautions that must be considered when we deal with human error

Chernobyl - system accident or human error?

International Nuclear Information System (INIS)

Stang, E.

1996-01-01

Did human error cause the Chernobyl disaster? The standard point of view is that operator error was the root cause of the disaster. This was also the view of the Soviet Accident Commission. The paper analyses the operator errors at Chernobyl in a system context. The reactor operators committed errors that depended upon a lot of other failures that made up a complex accident scenario. The analysis is based on Charles Perrow's analysis of technological disasters. Failure possibility is an inherent property of high-risk industrial installations. The Chernobyl accident consisted of a chain of events that were both extremely improbable and difficult to predict. It is not reasonable to put the blame for the disaster on the operators. (author)

Quality of IT service delivery — Analysis and framework for human error prevention

KAUST Repository

Shwartz, L.; Rosu, D.; Loewenstern, D.; Buco, M. J.; Guo, S.; Lavrado, Rafael Coelho; Gupta, M.; De, P.; Madduri, V.; Singh, J. K.

2010-01-01

In this paper, we address the problem of reducing the occurrence of Human Errors that cause service interruptions in IT Service Support and Delivery operations. Analysis of a large volume of service interruption records revealed that more than 21

Working group of experts on rare events in human error analysis and quantification

International Nuclear Information System (INIS)

Goodstein, L.P.

1977-01-01

In dealing with the reference problem of rare events in nuclear power plants, the group has concerned itself with the man-machine system and, in particular, with human error analysis and quantification. The Group was requested to review methods of human reliability prediction, to evaluate the extent to which such analyses can be formalized and to establish criteria to be met by task conditions and system design which would permit a systematic, formal analysis. Recommendations are given on the Fessenheim safety system

Systematic analysis of dependent human errors from the maintenance history at finnish NPPs - A status report

Energy Technology Data Exchange (ETDEWEB)

Laakso, K. [VTT Industrial Systems (Finland)

2002-12-01

Operating experience has shown missed detection events, where faults have passed inspections and functional tests to operating periods after the maintenance activities during the outage. The causes of these failures have often been complex event sequences, involving human and organisational factors. Especially common cause and other dependent failures of safety systems may significantly contribute to the reactor core damage risk. The topic has been addressed in the Finnish studies of human common cause failures, where experiences on latent human errors have been searched and analysed in detail from the maintenance history. The review of the bulk of the analysis results of the Olkiluoto and Loviisa plant sites shows that the instrumentation and control and electrical equipment is more prone to human error caused failure events than the other maintenance and that plant modifications and also predetermined preventive maintenance are significant sources of common cause failures. Most errors stem from the refuelling and maintenance outage period at the both sites, and less than half of the dependent errors were identified during the same outage. The dependent human errors originating from modifications could be reduced by a more tailored specification and coverage of their start-up testing programs. Improvements could also be achieved by a more case specific planning of the installation inspection and functional testing of complicated maintenance works or work objects of higher plant safety and availability importance. A better use and analysis of condition monitoring information for maintenance steering could also help. The feedback from discussions of the analysis results with plant experts and professionals is still crucial in developing the final conclusions and recommendations that meet the specific development needs at the plants. (au)

ATHEANA: A Technique for Human Error Analysis: An Overview of Its Methodological Basis

International Nuclear Information System (INIS)

Wreathall, John; Ramey-Smith, Ann

1998-01-01

The U.S. NRC has developed a new human reliability analysis (HRA) method, called A Technique for Human Event Analysis (ATHEANA), to provide a way of modeling the so-called 'errors of commission' - that is, situations in which operators terminate or disable engineered safety features (ESFs) or similar equipment during accident conditions, thereby putting the plant at an increased risk of core damage. In its reviews of operational events, NRC has found that these errors of commission occur with a relatively high frequency (as high as 2 or 3 per year), but are noticeably missing from the scope of most current probabilistic risk assessments (PRAs). This new method was developed through a formalized approach that describes what can occur when operators behave rationally but have inadequate knowledge or poor judgement. In particular, the method is based on models of decision-making and response planning that have been used extensively in the aviation field, and on the analysis of major accidents in both the nuclear and non-nuclear fields. Other papers at this conference present summaries of these event analyses in both the nuclear and non-nuclear fields. This paper presents an overview of ATHEANA and summarizes how the method structures the analysis of operationally significant events, and helps HRA analysts identify and model potentially risk-significant errors of commission in plant PRAs. (authors)

A Method and Support Tool for the Analysis of Human Error Hazards in Digital Devices

International Nuclear Information System (INIS)

Lee, Yong Hee; Kim, Seon Soo; Lee, Yong Hee

2012-01-01

In recent years, many nuclear power plants have adopted modern digital I and C technologies since they are expected to significantly improve their performance and safety. Modern digital technologies were expected to significantly improve both the economical efficiency and safety of nuclear power plants. However, the introduction of an advanced main control room (MCR) is accompanied with lots of changes in forms and features and differences through virtue of new digital devices. Many user-friendly displays and new features in digital devices are not enough to prevent human errors in nuclear power plants (NPPs). It may be an urgent to matter find the human errors potentials due to digital devices, and their detailed mechanisms. We can then consider them during the design of digital devices and their interfaces. The characteristics of digital technologies and devices may give many opportunities to the interface management, and can be integrated into a compact single workstation in an advanced MCR, such that workers can operate the plant with minimum burden under any operating condition. However, these devices may introduce new types of human errors, and thus we need a means to evaluate and prevent such errors, especially within digital devices for NPPs. This research suggests a new method named HEA-BIS (Human Error Analysis based on Interaction Segment) to confirm and detect human errors associated with digital devices. This method can be facilitated by support tools when used to ensure the safety when applying digital devices in NPPs

The common mode failures analysis of the redundent system with dependent human error

International Nuclear Information System (INIS)

Kim, M.K.; Chang, S.H.

1983-01-01

Common mode failures (CMFs) have been a serious concern in the nuclear power plant. Thereis a broad category of the failure mechanisms that can cause common mode failures. This paper is a theoretical investigation of the CMFs on the unavailability of the redundent system. It is assumed that the total CMFs consist of the potential CMFs and the dependent human error CMFs. As the human error dependency is higher, the total CMFs are more effected by the dependent human error. If the human error dependence is lower, the system unavailability strongly depends on the potential CMFs, rather than the mechanical failure or the dependent human error. And it is shown that the total CMFs are dominant factor to the unavailability of the redundent system. (Author)

Guidelines for system modeling: pre-accident human errors, rev.0

Energy Technology Data Exchange (ETDEWEB)

Kang, Dae Il; Jung, W. D.; Lee, Y. H.; Hwang, M. J.; Yang, J. E

2004-01-01

The evaluation results of Human Reliability Analysis (HRA) of pre-accident human errors in the probabilistic safety assessment (PSA) for the Korea Standard Nuclear Power Plant (KSNP) using the ASME PRA standard show that more than 50% of 10 items to be improved are related to the identification and screening analysis for them. Thus, we developed a guideline for modeling pre-accident human errors for the system analyst to resolve some items to be improved for them. The developed guideline consists of modeling criteria for the pre-accident human errors (identification, qualitative screening, and common restoration errors) and detailed guidelines for pre-accident human errors relating to testing, maintenance, and calibration works of nuclear power plants (NPPs). The system analyst use the developed guideline and he or she applies it to the system which he or she takes care of. The HRA analyst review the application results of the system analyst. We applied the developed guideline to the auxiliary feed water system of the KSNP to show the usefulness of it. The application results of the developed guideline show that more than 50% of the items to be improved for pre-accident human errors of auxiliary feed water system are resolved. The guideline for modeling pre-accident human errors developed in this study can be used for other NPPs as well as the KSNP. It is expected that both use of the detailed procedure, to be developed in the future, for the quantification of pre-accident human errors and the guideline developed in this study will greatly enhance the PSA quality in the HRA of pre-accident human errors.

Guidelines for system modeling: pre-accident human errors, rev.0

International Nuclear Information System (INIS)

Kang, Dae Il; Jung, W. D.; Lee, Y. H.; Hwang, M. J.; Yang, J. E.

2004-01-01

The evaluation results of Human Reliability Analysis (HRA) of pre-accident human errors in the probabilistic safety assessment (PSA) for the Korea Standard Nuclear Power Plant (KSNP) using the ASME PRA standard show that more than 50% of 10 items to be improved are related to the identification and screening analysis for them. Thus, we developed a guideline for modeling pre-accident human errors for the system analyst to resolve some items to be improved for them. The developed guideline consists of modeling criteria for the pre-accident human errors (identification, qualitative screening, and common restoration errors) and detailed guidelines for pre-accident human errors relating to testing, maintenance, and calibration works of nuclear power plants (NPPs). The system analyst use the developed guideline and he or she applies it to the system which he or she takes care of. The HRA analyst review the application results of the system analyst. We applied the developed guideline to the auxiliary feed water system of the KSNP to show the usefulness of it. The application results of the developed guideline show that more than 50% of the items to be improved for pre-accident human errors of auxiliary feed water system are resolved. The guideline for modeling pre-accident human errors developed in this study can be used for other NPPs as well as the KSNP. It is expected that both use of the detailed procedure, to be developed in the future, for the quantification of pre-accident human errors and the guideline developed in this study will greatly enhance the PSA quality in the HRA of pre-accident human errors

A theory of human error

Science.gov (United States)

Mcruer, D. T.; Clement, W. F.; Allen, R. W.

1981-01-01

Human errors tend to be treated in terms of clinical and anecdotal descriptions, from which remedial measures are difficult to derive. Correction of the sources of human error requires an attempt to reconstruct underlying and contributing causes of error from the circumstantial causes cited in official investigative reports. A comprehensive analytical theory of the cause-effect relationships governing propagation of human error is indispensable to a reconstruction of the underlying and contributing causes. A validated analytical theory of the input-output behavior of human operators involving manual control, communication, supervisory, and monitoring tasks which are relevant to aviation, maritime, automotive, and process control operations is highlighted. This theory of behavior, both appropriate and inappropriate, provides an insightful basis for investigating, classifying, and quantifying the needed cause-effect relationships governing propagation of human error.

Cause analysis and preventives for human error events in Daya Bay NPP

International Nuclear Information System (INIS)

Huang Weigang; Zhang Li

1998-01-01

Daya Bay Nuclear Power Plant is put into commercial operation in 1994 Until 1996, there are 368 human error events in operating and maintenance area, occupying 39% of total events. These events occurred mainly in the processes of maintenance, test equipment isolation and system on-line, in particular in refuelling and maintenance. The author analyses root causes for human errorievents, which are mainly operator omission or error procedure deficiency; procedure not followed; lack of training; communication failures; work management inadequacy. The protective measures and treatment principle for human error events are also discussed, and several examples applying them are given. Finally, it is put forward that key to prevent human error event lies in the coordination and management, person in charge of work, and good work habits of staffs

A Human Error Analysis Procedure for Identifying Potential Error Modes and Influencing Factors for Test and Maintenance Activities

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2010-01-01

Periodic or non-periodic test and maintenance (T and M) activities in large, complex systems such as nuclear power plants (NPPs) are essential for sustaining stable and safe operation of the systems. On the other hand, it also has been raised that human erroneous actions that might occur during T and M activities has the possibility of incurring unplanned reactor trips (RTs) or power derate, making safety-related systems unavailable, or making the reliability of components degraded. Contribution of human errors during normal and abnormal activities of NPPs to the unplanned RTs is known to be about 20% of the total events. This paper introduces a procedure for predictively analyzing human error potentials when maintenance personnel perform T and M tasks based on a work procedure or their work plan. This procedure helps plant maintenance team prepare for plausible human errors. The procedure to be introduced is focusing on the recurrent error forms (or modes) in execution-based errors such as wrong object, omission, too little, and wrong action

An Analysis and Quantification Method of Human Errors of Soft Controls in Advanced MCRs

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jae Whan; Jang, Seung Cheol

2011-01-01

In this work, a method was proposed for quantifying human errors that may occur during operation executions using soft control. Soft controls of advanced main control rooms (MCRs) have totally different features from conventional controls, and thus they may have different human error modes and occurrence probabilities. It is important to define the human error modes and to quantify the error probability for evaluating the reliability of the system and preventing errors. This work suggests a modified K-HRA method for quantifying error probability

The role of human error in risk analysis: Application to pre- and post-maintenance procedures of process facilities

International Nuclear Information System (INIS)

Noroozi, Alireza; Khakzad, Nima; Khan, Faisal; MacKinnon, Scott; Abbassi, Rouzbeh

2013-01-01

Human factors play an important role in the safe operation of a facility. Human factors include the systematic application of information about human characteristics and behavior to increase the safety of a process system. A significant proportion of human errors occur during the maintenance phase. However, the quantification of human error probabilities in the maintenance phase has not been given the amount of attention it deserves. This paper focuses on a human factors analysis in pre-and post- pump maintenance operations. The procedures for removing process equipment from service (pre-maintenance) and returning the equipment to service (post-maintenance) are considered for possible failure scenarios. For each scenario, human error probability is calculated for each activity using the Success Likelihood Index Method (SLIM). Consequences are also assessed in this methodology. The risk assessment is conducted for each component and the overall risk is estimated by adding individual risks. The present study is aimed at highlighting the importance of considering human error in quantitative risk analyses. The developed methodology has been applied to a case study of an offshore process facility

A basic framework for the analysis of the human error potential due to the computerization in nuclear power plants

International Nuclear Information System (INIS)

Lee, Y. H.

1999-01-01

Computerization and its vivid benefits expected in the nuclear power plant design cannot be realized without verifying the inherent safety problems. Human error aspect is also included in the verification issues. The verification spans from the perception of the changes in operation functions such as automation to the unfamiliar experience of operators due to the interface change. Therefore, a new framework for human error analysis might capture both the positive and the negative effect of the computerization. This paper suggest a basic framework for error identification through the review of the existing human error studies and the experience of computerizations in nuclear power plants

Demonstration Integrated Knowledge-Based System for Estimating Human Error Probabilities

Energy Technology Data Exchange (ETDEWEB)

Auflick, Jack L.

1999-04-21

Human Reliability Analysis (HRA) is currently comprised of at least 40 different methods that are used to analyze, predict, and evaluate human performance in probabilistic terms. Systematic HRAs allow analysts to examine human-machine relationships, identify error-likely situations, and provide estimates of relative frequencies for human errors on critical tasks, highlighting the most beneficial areas for system improvements. Unfortunately, each of HRA's methods has a different philosophical approach, thereby producing estimates of human error probabilities (HEPs) that area better or worse match to the error likely situation of interest. Poor selection of methodology, or the improper application of techniques can produce invalid HEP estimates, where that erroneous estimation of potential human failure could have potentially severe consequences in terms of the estimated occurrence of injury, death, and/or property damage.

HUMAN ERROR QUANTIFICATION USING PERFORMANCE SHAPING FACTORS IN THE SPAR-H METHOD

Energy Technology Data Exchange (ETDEWEB)

Harold S. Blackman; David I. Gertman; Ronald L. Boring

2008-09-01

This paper describes a cognitively based human reliability analysis (HRA) quantification technique for estimating the human error probabilities (HEPs) associated with operator and crew actions at nuclear power plants. The method described here, Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) method, was developed to aid in characterizing and quantifying human performance at nuclear power plants. The intent was to develop a defensible method that would consider all factors that may influence performance. In the SPAR-H approach, calculation of HEP rates is especially straightforward, starting with pre-defined nominal error rates for cognitive vs. action-oriented tasks, and incorporating performance shaping factor multipliers upon those nominal error rates.

FRamework Assessing Notorious Contributing Influences for Error (FRANCIE): Perspective on Taxonomy Development to Support Error Reporting and Analysis

Energy Technology Data Exchange (ETDEWEB)

Lon N. Haney; David I. Gertman

2003-04-01

Beginning in the 1980s a primary focus of human reliability analysis was estimation of human error probabilities. However, detailed qualitative modeling with comprehensive representation of contextual variables often was lacking. This was likely due to the lack of comprehensive error and performance shaping factor taxonomies, and the limited data available on observed error rates and their relationship to specific contextual variables. In the mid 90s Boeing, America West Airlines, NASA Ames Research Center and INEEL partnered in a NASA sponsored Advanced Concepts grant to: assess the state of the art in human error analysis, identify future needs for human error analysis, and develop an approach addressing these needs. Identified needs included the need for a method to identify and prioritize task and contextual characteristics affecting human reliability. Other needs identified included developing comprehensive taxonomies to support detailed qualitative modeling and to structure meaningful data collection efforts across domains. A result was the development of the FRamework Assessing Notorious Contributing Influences for Error (FRANCIE) with a taxonomy for airline maintenance tasks. The assignment of performance shaping factors to generic errors by experts proved to be valuable to qualitative modeling. Performance shaping factors and error types from such detailed approaches can be used to structure error reporting schemes. In a recent NASA Advanced Human Support Technology grant FRANCIE was refined, and two new taxonomies for use on space missions were developed. The development, sharing, and use of error taxonomies, and the refinement of approaches for increased fidelity of qualitative modeling is offered as a means to help direct useful data collection strategies.

Human Errors and Bridge Management Systems

DEFF Research Database (Denmark)

Thoft-Christensen, Palle; Nowak, A. S.

on basis of reliability profiles for bridges without human errors are extended to include bridges with human errors. The first rehabilitation distributions for bridges without and with human errors are combined into a joint first rehabilitation distribution. The methodology presented is illustrated...... for reinforced concrete bridges....

Study on a new framework of Human Reliability Analysis to evaluate soft control execution error in advanced MCRs of NPPs

International Nuclear Information System (INIS)

Jang, Inseok; Kim, Ar Ryum; Jung, Wondea; Seong, Poong Hyun

2016-01-01

Highlights: • The operation environment of MCRs in NPPs has changed by adopting new HSIs. • The operation action in NPP Advanced MCRs is performed by soft control. • New HRA framework should be considered in the HRA for advanced MCRs. • HRA framework for evaluation of soft control execution human error is suggested. • Suggested method will be helpful to analyze human reliability in advance MCRs. - Abstract: Since the Three Mile Island (TMI)-2 accident, human error has been recognized as one of the main causes of Nuclear Power Plant (NPP) accidents, and numerous studies related to Human Reliability Analysis (HRA) have been carried out. Most of these methods were developed considering the conventional type of Main Control Rooms (MCRs). However, the operating environment of MCRs in NPPs has changed with the adoption of new Human-System Interfaces (HSIs) that are based on computer-based technologies. The MCRs that include these digital technologies, such as large display panels, computerized procedures, and soft controls, are called advanced MCRs. Among the many features of advanced MCRs, soft controls are a particularly important feature because operating actions in NPP advanced MCRs are performed by soft control. Due to the differences in interfaces between soft control and hardwired conventional type control, different Human Error Probabilities (HEPs) and a new HRA framework should be considered in the HRA for advanced MCRs. To this end, a new framework of a HRA method for evaluating soft control execution human error is suggested by performing a soft control task analysis and the literature regarding widely accepted human error taxonomies is reviewed. Moreover, since most current HRA databases deal with operation in conventional MCRs and are not explicitly designed to deal with digital HSIs, empirical analysis of human error and error recovery considering soft controls under an advanced MCR mockup are carried out to collect human error data, which is

Development and evaluation of a computer-aided system for analyzing human error in railway operations

International Nuclear Information System (INIS)

Kim, Dong San; Baek, Dong Hyun; Yoon, Wan Chul

2010-01-01

As human error has been recognized as one of the major contributors to accidents in safety-critical systems, there has been a strong need for techniques that can analyze human error effectively. Although many techniques have been developed so far, much room for improvement remains. As human error analysis is a cognitively demanding and time-consuming task, it is particularly necessary to develop a computerized system supporting this task. This paper presents a computer-aided system for analyzing human error in railway operations, called Computer-Aided System for Human Error Analysis and Reduction (CAS-HEAR). It supports analysts to find multiple levels of error causes and their causal relations by using predefined links between contextual factors and causal factors as well as links between causal factors. In addition, it is based on a complete accident model; hence, it helps analysts to conduct a thorough analysis without missing any important part of human error analysis. A prototype of CAS-HEAR was evaluated by nine field investigators from six railway organizations in Korea. Its overall usefulness in human error analysis was confirmed, although development of its simplified version and some modification of the contextual factors and causal factors are required in order to ensure its practical use.

Human errors, countermeasures for their prevention and evaluation

International Nuclear Information System (INIS)

Kohda, Takehisa; Inoue, Koichi

1992-01-01

The accidents originated in human errors have occurred as ever in recent large accidents such as the TMI accident and the Chernobyl accident. The proportion of the accidents originated in human errors is unexpectedly high, therefore, the reliability and safety of hardware are improved hereafter, but the improvement of human reliability cannot be expected. Human errors arise by the difference between the function required for men and the function actually accomplished by men, and the results exert some adverse effect to systems. Human errors are classified into design error, manufacture error, operation error, maintenance error, checkup error and general handling error. In terms of behavior, human errors are classified into forget to do, fail to do, do that must not be done, mistake in order and do at improper time. The factors in human error occurrence are circumstantial factor, personal factor and stress factor. As the method of analyzing and evaluating human errors, system engineering method such as probabilistic risk assessment is used. The technique for human error rate prediction, the method for human cognitive reliability, confusion matrix and SLIM-MAUD are also used. (K.I.)

Research trend on human error reduction

International Nuclear Information System (INIS)

Miyaoka, Sadaoki

1990-01-01

Human error has been the problem in all industries. In 1988, the Bureau of Mines, Department of the Interior, USA, carried out the worldwide survey on the human error in all industries in relation to the fatal accidents in mines. There was difference in the results according to the methods of collecting data, but the proportion that human error took in the total accidents distributed in the wide range of 20∼85%, and was 35% on the average. The rate of occurrence of accidents and troubles in Japanese nuclear power stations is shown, and the rate of occurrence of human error is 0∼0.5 cases/reactor-year, which did not much vary. Therefore, the proportion that human error took in the total tended to increase, and it has become important to reduce human error for lowering the rate of occurrence of accidents and troubles hereafter. After the TMI accident in 1979 in USA, the research on man-machine interface became active, and after the Chernobyl accident in 1986 in USSR, the problem of organization and management has been studied. In Japan, 'Safety 21' was drawn up by the Advisory Committee for Energy, and also the annual reports on nuclear safety pointed out the importance of human factors. The state of the research on human factors in Japan and abroad and three targets to reduce human error are reported. (K.I.)

Monte Carlo simulation of expert judgments on human errors in chemical analysis--a case study of ICP-MS.

Science.gov (United States)

Kuselman, Ilya; Pennecchi, Francesca; Epstein, Malka; Fajgelj, Ales; Ellison, Stephen L R

2014-12-01

Monte Carlo simulation of expert judgments on human errors in a chemical analysis was used for determination of distributions of the error quantification scores (scores of likelihood and severity, and scores of effectiveness of a laboratory quality system in prevention of the errors). The simulation was based on modeling of an expert behavior: confident, reasonably doubting and irresolute expert judgments were taken into account by means of different probability mass functions (pmfs). As a case study, 36 scenarios of human errors which may occur in elemental analysis of geological samples by ICP-MS were examined. Characteristics of the score distributions for three pmfs of an expert behavior were compared. Variability of the scores, as standard deviation of the simulated score values from the distribution mean, was used for assessment of the score robustness. A range of the score values, calculated directly from elicited data and simulated by a Monte Carlo method for different pmfs, was also discussed from the robustness point of view. It was shown that robustness of the scores, obtained in the case study, can be assessed as satisfactory for the quality risk management and improvement of a laboratory quality system against human errors. Copyright © 2014 Elsevier B.V. All rights reserved.

A method for analysing incidents due to human errors on nuclear installations

International Nuclear Information System (INIS)

Griffon, M.

1980-01-01

This paper deals with the development of a methodology adapted to a detailed analysis of incidents considered to be due to human errors. An identification of human errors and a search for their eventual multiple causes is then needed. They are categorized in eight classes: education and training of personnel, installation design, work organization, time and work duration, physical environment, social environment, history of the plant and performance of the operator. The method is illustrated by the analysis of a handling incident generated by multiple human errors. (author)

Detailed semantic analyses of human error incidents occurring at nuclear power plant in USA (interim report). Characteristics of human error incidents occurring in the period from 1992 to 1996

International Nuclear Information System (INIS)

Hirotsu, Yuko; Tsuge, Tadashi; Sano, Toshiaki; Takano, Kenichi; Gouda, Hidenori

2001-01-01

CRIEPI has been conducting detailed analyses of all human error incidents at domestic nuclear power plants (NPPs) collected from Japanese Licensee Event Reports (LERs) using J-HPES (Japanese version of HPES) as an analysis method. Results obtained by the analyses have been stored in J-HPES database. Since 1999, human error incidents have been selected from U.S. LERs, and they are analyzed using J-HPES. In this report, the results, which classified error action, cause, and preventive measure, are summarized for U.S. human error cases occurring in the period from 1992 to 1996. It was suggested as a result of classification that the categories of error action were almost the same as those of Japanese human error cases. Therefore, problems in the process of error action and checkpoints for preventing errors will be extracted by analyzing both U.S. and domestic human error cases. It was also suggested that the interrelations between error actions, causes, and organizational factors could be identified. While taking these suggestions into consideration, we will continue to analyze U.S. human error cases. (author)

Modeling Human Error Mechanism for Soft Control in Advanced Control Rooms (ACRs)

Energy Technology Data Exchange (ETDEWEB)

Aljneibi, Hanan Salah Ali [Khalifa Univ., Abu Dhabi (United Arab Emirates); Ha, Jun Su; Kang, Seongkeun; Seong, Poong Hyun [KAIST, Daejeon (Korea, Republic of)

2015-10-15

To achieve the switch from conventional analog-based design to digital design in ACRs, a large number of manual operating controls and switches have to be replaced by a few common multi-function devices which is called soft control system. The soft controls in APR-1400 ACRs are classified into safety-grade and non-safety-grade soft controls; each was designed using different and independent input devices in ACRs. The operations using soft controls require operators to perform new tasks which were not necessary in conventional controls such as navigating computerized displays to monitor plant information and control devices. These kinds of computerized displays and soft controls may make operations more convenient but they might cause new types of human error. In this study the human error mechanism during the soft controls is studied and modeled to be used for analysis and enhancement of human performance (or human errors) during NPP operation. The developed model would contribute to a lot of applications to improve human performance (or reduce human errors), HMI designs, and operators' training program in ACRs. The developed model of human error mechanism for the soft control is based on assumptions that a human operator has certain amount of capacity in cognitive resources and if resources required by operating tasks are greater than resources invested by the operator, human error (or poor human performance) is likely to occur (especially in 'slip'); good HMI (Human-machine Interface) design decreases the required resources; operator's skillfulness decreases the required resources; and high vigilance increases the invested resources. In this study the human error mechanism during the soft controls is studied and modeled to be used for analysis and enhancement of human performance (or reduction of human errors) during NPP operation.

Modeling Human Error Mechanism for Soft Control in Advanced Control Rooms (ACRs)

International Nuclear Information System (INIS)

Aljneibi, Hanan Salah Ali; Ha, Jun Su; Kang, Seongkeun; Seong, Poong Hyun

2015-01-01

To achieve the switch from conventional analog-based design to digital design in ACRs, a large number of manual operating controls and switches have to be replaced by a few common multi-function devices which is called soft control system. The soft controls in APR-1400 ACRs are classified into safety-grade and non-safety-grade soft controls; each was designed using different and independent input devices in ACRs. The operations using soft controls require operators to perform new tasks which were not necessary in conventional controls such as navigating computerized displays to monitor plant information and control devices. These kinds of computerized displays and soft controls may make operations more convenient but they might cause new types of human error. In this study the human error mechanism during the soft controls is studied and modeled to be used for analysis and enhancement of human performance (or human errors) during NPP operation. The developed model would contribute to a lot of applications to improve human performance (or reduce human errors), HMI designs, and operators' training program in ACRs. The developed model of human error mechanism for the soft control is based on assumptions that a human operator has certain amount of capacity in cognitive resources and if resources required by operating tasks are greater than resources invested by the operator, human error (or poor human performance) is likely to occur (especially in 'slip'); good HMI (Human-machine Interface) design decreases the required resources; operator's skillfulness decreases the required resources; and high vigilance increases the invested resources. In this study the human error mechanism during the soft controls is studied and modeled to be used for analysis and enhancement of human performance (or reduction of human errors) during NPP operation

Systematic analysis of video data from different human-robot interaction studies: a categorization of social signals during error situations.

Science.gov (United States)

Giuliani, Manuel; Mirnig, Nicole; Stollnberger, Gerald; Stadler, Susanne; Buchner, Roland; Tscheligi, Manfred

2015-01-01

Human-robot interactions are often affected by error situations that are caused by either the robot or the human. Therefore, robots would profit from the ability to recognize when error situations occur. We investigated the verbal and non-verbal social signals that humans show when error situations occur in human-robot interaction experiments. For that, we analyzed 201 videos of five human-robot interaction user studies with varying tasks from four independent projects. The analysis shows that there are two types of error situations: social norm violations and technical failures. Social norm violations are situations in which the robot does not adhere to the underlying social script of the interaction. Technical failures are caused by technical shortcomings of the robot. The results of the video analysis show that the study participants use many head movements and very few gestures, but they often smile, when in an error situation with the robot. Another result is that the participants sometimes stop moving at the beginning of error situations. We also found that the participants talked more in the case of social norm violations and less during technical failures. Finally, the participants use fewer non-verbal social signals (for example smiling, nodding, and head shaking), when they are interacting with the robot alone and no experimenter or other human is present. The results suggest that participants do not see the robot as a social interaction partner with comparable communication skills. Our findings have implications for builders and evaluators of human-robot interaction systems. The builders need to consider including modules for recognition and classification of head movements to the robot input channels. The evaluators need to make sure that the presence of an experimenter does not skew the results of their user studies.

Human error probability evaluation as part of reliability analysis of digital protection system of advanced pressurized water reactor - APR 1400

International Nuclear Information System (INIS)

Varde, P. V.; Lee, D. Y.; Han, J. B.

2003-03-01

A case of study on human reliability analysis has been performed as part of reliability analysis of digital protection system of the reactor automatically actuates the shutdown system of the reactor when demanded. However, the safety analysis takes credit for operator action as a diverse mean for tripping the reactor for, though a low probability, ATWS scenario. Based on the available information two cases, viz., human error in tripping the reactor and calibration error for instrumentations in protection system, have been analyzed. Wherever applicable a parametric study has also been performed

Collection of offshore human error probability data

International Nuclear Information System (INIS)

Basra, Gurpreet; Kirwan, Barry

1998-01-01

Accidents such as Piper Alpha have increased concern about the effects of human errors in complex systems. Such accidents can in theory be predicted and prevented by risk assessment, and in particular human reliability assessment (HRA), but HRA ideally requires qualitative and quantitative human error data. A research initiative at the University of Birmingham led to the development of CORE-DATA, a Computerised Human Error Data Base. This system currently contains a reasonably large number of human error data points, collected from a variety of mainly nuclear-power related sources. This article outlines a recent offshore data collection study, concerned with collecting lifeboat evacuation data. Data collection methods are outlined and a selection of human error probabilities generated as a result of the study are provided. These data give insights into the type of errors and human failure rates that could be utilised to support offshore risk analyses

Evaluation of human error estimation for nuclear power plants

International Nuclear Information System (INIS)

Haney, L.N.; Blackman, H.S.

1987-01-01

The dominant risk for severe accident occurrence in nuclear power plants (NPPs) is human error. The US Nuclear Regulatory Commission (NRC) sponsored an evaluation of Human Reliability Analysis (HRA) techniques for estimation of human error in NPPs. Twenty HRA techniques identified by a literature search were evaluated with criteria sets designed for that purpose and categorized. Data were collected at a commercial NPP with operators responding in walkthroughs of four severe accident scenarios and full scope simulator runs. Results suggest a need for refinement and validation of the techniques. 19 refs

The Human Bathtub: Safety and Risk Predictions Including the Dynamic Probability of Operator Errors

International Nuclear Information System (INIS)

Duffey, Romney B.; Saull, John W.

2006-01-01

Reactor safety and risk are dominated by the potential and major contribution for human error in the design, operation, control, management, regulation and maintenance of the plant, and hence to all accidents. Given the possibility of accidents and errors, now we need to determine the outcome (error) probability, or the chance of failure. Conventionally, reliability engineering is associated with the failure rate of components, or systems, or mechanisms, not of human beings in and interacting with a technological system. The probability of failure requires a prior knowledge of the total number of outcomes, which for any predictive purposes we do not know or have. Analysis of failure rates due to human error and the rate of learning allow a new determination of the dynamic human error rate in technological systems, consistent with and derived from the available world data. The basis for the analysis is the 'learning hypothesis' that humans learn from experience, and consequently the accumulated experience defines the failure rate. A new 'best' equation has been derived for the human error, outcome or failure rate, which allows for calculation and prediction of the probability of human error. We also provide comparisons to the empirical Weibull parameter fitting used in and by conventional reliability engineering and probabilistic safety analysis methods. These new analyses show that arbitrary Weibull fitting parameters and typical empirical hazard function techniques cannot be used to predict the dynamics of human errors and outcomes in the presence of learning. Comparisons of these new insights show agreement with human error data from the world's commercial airlines, the two shuttle failures, and from nuclear plant operator actions and transient control behavior observed in transients in both plants and simulators. The results demonstrate that the human error probability (HEP) is dynamic, and that it may be predicted using the learning hypothesis and the minimum

The development of human behaviour analysis techniques -The development of human factors technologies-

International Nuclear Information System (INIS)

Lee, Jung Woon; Cheon, Se Woo; Shu, Sang Moon; Park, Geun Ok; Lee, Yong Hee; Lee, Han Yeong; Park, Jae Chang; Lee, Eu Jin; Lee, Seung Hee

1994-04-01

This project has two major areas ; one is the development of an operator task simulation software and another is the development of human error analysis and application technologies. In this year project, the second year, for the development of an operator task simulation software, we studied the followings: - analysis of the characteristics of operator tasks, - development of operator task structures : Macro Structures, - development of an operator task simulation analyzes, - analysis of performance measures. And the followings for the development of human error analysis and application technologies : - analysis of human error mechanisms, - analysis of human error characteristics in tasks, - analysis of human error occurrence in Korean Nuclear Power Plants, - establishment of an experimental environment for human error data collection with Compact Nuclear Simulator, - basic design of a Multimedia-based Human Error Representing System. (Author)

Using HET taxonomy to help stop human error

OpenAIRE

Li, Wen-Chin; Harris, Don; Stanton, Neville A.; Hsu, Yueh-Ling; Chang, Danny; Wang, Thomas; Young, Hong-Tsu

2010-01-01

Flight crews make positive contributions to the safety of aviation operations. Pilots have to assess continuously changing situations, evaluate potential risks, and make quick decisions. However, even well-trained and experienced pilots make errors. Accident investigations have identified that pilots’ performance is influenced significantly by the design of the flightdeck interface. This research applies hierarchical task analysis (HTA) and utilizes the Human Error Template (HET) taxonomy to ...

Human error in maintenance: An investigative study for the factories of the future

International Nuclear Information System (INIS)

Dhillon, B S

2014-01-01

This paper presents a study of human error in maintenance. Many different aspects of human error in maintenance considered useful for the factories of the future are studied, including facts, figures, and examples; occurrence of maintenance error in equipment life cycle, elements of a maintenance person's time, maintenance environment and the causes for the occurrence of maintenance error, types and typical maintenance errors, common maintainability design errors and useful design guidelines to reduce equipment maintenance errors, maintenance work instructions, and maintenance error analysis methods

Human reliability analysis of errors of commission: a review of methods and applications

Energy Technology Data Exchange (ETDEWEB)

Reer, B

2007-06-15

Illustrated by specific examples relevant to contemporary probabilistic safety assessment (PSA), this report presents a review of human reliability analysis (HRA) addressing post initiator errors of commission (EOCs), i.e. inappropriate actions under abnormal operating conditions. The review addressed both methods and applications. Emerging HRA methods providing advanced features and explicit guidance suitable for PSA are: A Technique for Human Event Analysis (ATHEANA, key publications in 1998/2000), Methode d'Evaluation de la Realisation des Missions Operateur pour la Surete (MERMOS, 1998/2000), the EOC HRA method developed by the Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS, 2003), the Misdiagnosis Tree Analysis (MDTA) method (2005/2006), the Cognitive Reliability and Error Analysis Method (CREAM, 1998), and the Commission Errors Search and Assessment (CESA) method (2002/2004). As a result of a thorough investigation of various PSA/HRA applications, this paper furthermore presents an overview of EOCs (termination of safety injection, shutdown of secondary cooling, etc.) referred to in predictive studies and a qualitative review of cases of EOC quantification. The main conclusions of the review of both the methods and the EOC HRA cases are: (1) The CESA search scheme, which proceeds from possible operator actions to the affected systems to scenarios, may be preferable because this scheme provides a formalized way for identifying relatively important scenarios with EOC opportunities; (2) an EOC identification guidance like CESA, which is strongly based on the procedural guidance and important measures of systems or components affected by inappropriate actions, however should pay some attention to EOCs associated with familiar but non-procedural actions and EOCs leading to failures of manually initiated safety functions. (3) Orientations of advanced EOC quantification comprise a) modeling of multiple contexts for a given scenario, b) accounting for

Human reliability analysis of errors of commission: a review of methods and applications

International Nuclear Information System (INIS)

Reer, B.

2007-06-01

Illustrated by specific examples relevant to contemporary probabilistic safety assessment (PSA), this report presents a review of human reliability analysis (HRA) addressing post initiator errors of commission (EOCs), i.e. inappropriate actions under abnormal operating conditions. The review addressed both methods and applications. Emerging HRA methods providing advanced features and explicit guidance suitable for PSA are: A Technique for Human Event Analysis (ATHEANA, key publications in 1998/2000), Methode d'Evaluation de la Realisation des Missions Operateur pour la Surete (MERMOS, 1998/2000), the EOC HRA method developed by the Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS, 2003), the Misdiagnosis Tree Analysis (MDTA) method (2005/2006), the Cognitive Reliability and Error Analysis Method (CREAM, 1998), and the Commission Errors Search and Assessment (CESA) method (2002/2004). As a result of a thorough investigation of various PSA/HRA applications, this paper furthermore presents an overview of EOCs (termination of safety injection, shutdown of secondary cooling, etc.) referred to in predictive studies and a qualitative review of cases of EOC quantification. The main conclusions of the review of both the methods and the EOC HRA cases are: (1) The CESA search scheme, which proceeds from possible operator actions to the affected systems to scenarios, may be preferable because this scheme provides a formalized way for identifying relatively important scenarios with EOC opportunities; (2) an EOC identification guidance like CESA, which is strongly based on the procedural guidance and important measures of systems or components affected by inappropriate actions, however should pay some attention to EOCs associated with familiar but non-procedural actions and EOCs leading to failures of manually initiated safety functions. (3) Orientations of advanced EOC quantification comprise a) modeling of multiple contexts for a given scenario, b) accounting for

Savannah River Site human error data base development for nonreactor nuclear facilities

International Nuclear Information System (INIS)

Benhardt, H.C.; Held, J.E.; Olsen, L.M.; Vail, R.E.; Eide, S.A.

1994-01-01

As part of an overall effort to upgrade and streamline methodologies for safety analyses of nonreactor nuclear facilities at the Savannah River Site (SRS), a human error data base has been developed and is presented in this report. The data base fulfills several needs of risk analysts supporting safety analysis report (SAR) development. First, it provides a single source for probabilities or rates for a wide variety of human errors associated with the SRS nonreactor nuclear facilities. Second, it provides a documented basis for human error probabilities or rates. And finally, it provides actual SRS-specific human error data to support many of the error probabilities or rates. Use of a single, documented reference source for human errors, supported by SRS-specific human error data, will improve the consistency and accuracy of human error modeling by SRS risk analysts. It is envisioned that SRS risk analysts will use this report as both a guide to identifying the types of human errors that may need to be included in risk models such as fault and event trees, and as a source for human error probabilities or rates. For each human error in this report, ffime different mean probabilities or rates are presented to cover a wide range of conditions and influencing factors. The ask analysts must decide which mean value is most appropriate for each particular application. If other types of human errors are needed for the risk models, the analyst must use other sources. Finally, if human enors are dominant in the quantified risk models (based on the values obtained fmm this report), then it may be appropriate to perform detailed human reliability analyses (HRAS) for the dominant events. This document does not provide guidance for such refined HRAS; in such cases experienced human reliability analysts should be involved

Development of an integrated system for estimating human error probabilities

Energy Technology Data Exchange (ETDEWEB)

Auflick, J.L.; Hahn, H.A.; Morzinski, J.A.

1998-12-01

This is the final report of a three-year, Laboratory Directed Research and Development (LDRD) project at the Los Alamos National Laboratory (LANL). This project had as its main objective the development of a Human Reliability Analysis (HRA), knowledge-based expert system that would provide probabilistic estimates for potential human errors within various risk assessments, safety analysis reports, and hazard assessments. HRA identifies where human errors are most likely, estimates the error rate for individual tasks, and highlights the most beneficial areas for system improvements. This project accomplished three major tasks. First, several prominent HRA techniques and associated databases were collected and translated into an electronic format. Next, the project started a knowledge engineering phase where the expertise, i.e., the procedural rules and data, were extracted from those techniques and compiled into various modules. Finally, these modules, rules, and data were combined into a nearly complete HRA expert system.

Information Management System Development for the Characterization and Analysis of Human Error in Naval Aviation Maintenance Related Mishaps

National Research Council Canada - National Science Library

Wood, Brian

2000-01-01

.... The Human Factors Analysis and Classification System-Maintenance Extension taxonomy, an effective framework for classifying and analyzing the presence of maintenance errors that lead to mishaps...

New method of classifying human errors at nuclear power plants and the analysis results of applying this method to maintenance errors at domestic plants

International Nuclear Information System (INIS)

Takagawa, Kenichi; Miyazaki, Takamasa; Gofuku, Akio; Iida, Hiroyasu

2007-01-01

Since many of the adverse events that have occurred in nuclear power plants in Japan and abroad have been related to maintenance or operation, it is necessary to plan preventive measures based on detailed analyses of human errors made by maintenance workers or operators. Therefore, before planning preventive measures, we developed a new method of analyzing human errors. Since each human error is an unsafe action caused by some misjudgement made by a person, we decided to classify them into six categories according to the stage in the judgment process in which the error was made. By further classifying each error into either an omission-type or commission-type, we produced 12 categories of errors. Then, we divided them into the two categories of basic error tendencies and individual error tendencies, and categorized background factors into four categories: imperfect planning; imperfect facilities or tools; imperfect environment; and imperfect instructions or communication. We thus defined the factors in each category to make it easy to identify factors that caused the error. Then using this method, we studied the characteristics of human errors that involved maintenance workers and planners since many maintenance errors have occurred. Among the human errors made by workers (worker errors) during the implementation stage, the following three types were prevalent with approximately 80%: commission-type 'projection errors', omission-type comprehension errors' and commission type 'action errors'. The most common among the individual factors of worker errors was 'repetition or habit' (schema), based on the assumption of a typical situation, and the half number of the 'repetition or habit' cases (schema) were not influenced by any background factors. The most common background factor that contributed to the individual factor was 'imperfect work environment', followed by 'insufficient knowledge'. Approximately 80% of the individual factors were 'repetition or habit' or

Review of U.S. Army Unmanned Aerial Systems Accident Reports: Analysis of Human Error Contributions

Science.gov (United States)

2018-03-20

within report documents. The information presented was obtained through a request to use the U.S. Army Combat Readiness Center’s Risk Management ...controlled flight into terrain (13 accidents), fueling errors by improper techniques (7 accidents), and a variety of maintenance errors (10 accidents). The...and 9 of the 10 maintenance accidents. Table 4. Frequencies Based on Source of Human Error Human error source Presence Poor Planning

Human error as a source of disturbances in Swedish nuclear power plants

International Nuclear Information System (INIS)

Sokolowski, E.

1985-01-01

Events involving human errors at the Swedish nuclear power plants are registered and periodically analyzed. The philosophy behind the scheme for data collection and analysis is discussed. Human errors cause about 10% of the disturbances registered. Only a small part of these errors are committed by operators in the control room. These and other findings differ from those in other countries. Possible reasons are put forward

Review of advances in human reliability analysis of errors of commission, Part 1: EOC identification

International Nuclear Information System (INIS)

Reer, Bernhard

2008-01-01

In close connection with examples relevant to contemporary probabilistic safety assessment (PSA), a review of advances in human reliability analysis (HRA) of post-initiator errors of commission (EOCs), i.e. inappropriate actions under abnormal operating conditions, has been carried out. The review comprises both EOC identification (part 1) and quantification (part 2); part 1 is presented in this article. Emerging HRA methods addressing the problem of EOC identification are: A Technique for Human Event Analysis (ATHEANA), the EOC HRA method developed by Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS), the Misdiagnosis Tree Analysis (MDTA) method, and the Commission Errors Search and Assessment (CESA) method. Most of the EOCs referred to in predictive studies comprise the stop of running or the inhibition of anticipated functions; a few comprise the start of a function. The CESA search scheme-which proceeds from possible operator actions to the affected systems to scenarios and uses procedures and importance measures as key sources of input information-provides a formalized way for identifying relatively important scenarios with EOC opportunities. In the implementation however, attention should be paid regarding EOCs associated with familiar but non-procedural actions and EOCs leading to failures of manually initiated safety functions

Human error in remote Afterloading Brachytherapy

International Nuclear Information System (INIS)

Quinn, M.L.; Callan, J.; Schoenfeld, I.; Serig, D.

1994-01-01

Remote Afterloading Brachytherapy (RAB) is a medical process used in the treatment of cancer. RAB uses a computer-controlled device to remotely insert and remove radioactive sources close to a target (or tumor) in the body. Some RAB problems affecting the radiation dose to the patient have been reported and attributed to human error. To determine the root cause of human error in the RAB system, a human factors team visited 23 RAB treatment sites in the US. The team observed RAB treatment planning and delivery, interviewed RAB personnel, and performed walk-throughs, during which staff demonstrated the procedures and practices used in performing RAB tasks. Factors leading to human error in the RAB system were identified. The impact of those factors on the performance of RAB was then evaluated and prioritized in terms of safety significance. Finally, the project identified and evaluated alternative approaches for resolving the safety significant problems related to human error

A strategy to the development of a human error analysis method for accident management in nuclear power plants using industrial accident dynamics

International Nuclear Information System (INIS)

Lee, Yong Hee; Kim, Jae Whan; Jung, Won Dae; Ha, Jae Ju

1998-06-01

This technical report describes the early progress of he establishment of a human error analysis method as a part of a human reliability analysis(HRA) method for the assessment of the human error potential in a given accident management strategy. At first, we review the shortages and limitations of the existing HRA methods through an example application. In order to enhance the bias to the quantitative aspect of the HRA method, we focused to the qualitative aspect, i.e., human error analysis(HEA), during the proposition of a strategy to the new method. For the establishment of a new HEA method, we discuss the basic theories and approaches to the human error in industry, and propose three basic requirements that should be maintained as pre-requisites for HEA method in practice. Finally, we test IAD(Industrial Accident Dynamics) which has been widely utilized in industrial fields, in order to know whether IAD can be so easily modified and extended to the nuclear power plant applications. We try to apply IAD to the same example case and develop new taxonomy of the performance shaping factors in accident management and their influence matrix, which could enhance the IAD method as an HEA method. (author). 33 refs., 17 tabs., 20 figs

Human error in strabismus surgery: Quantification with a sensitivity analysis

NARCIS (Netherlands)

S. Schutte (Sander); J.R. Polling (Jan Roelof); F.C.T. van der Helm (Frans); H.J. Simonsz (Huib)

2009-01-01

textabstractBackground: Reoperations are frequently necessary in strabismus surgery. The goal of this study was to analyze human-error related factors that introduce variability in the results of strabismus surgery in a systematic fashion. Methods: We identified the primary factors that influence

Can human error theory explain non-adherence?

Science.gov (United States)

Barber, Nick; Safdar, A; Franklin, Bryoney D

2005-08-01

To apply human error theory to explain non-adherence and examine how well it fits. Patients who were taking chronic medication were telephoned and asked whether they had been adhering to their medicine, and if not the reasons were explored and analysed according to a human error theory. Of 105 patients, 87 were contacted by telephone and they took part in the study. Forty-two recalled being non-adherent, 17 of them in the last 7 days; 11 of the 42 were intentionally non-adherent. The errors could be described by human error theory, and it explained unintentional non-adherence well, however, the application of 'rules' was difficult when considering mistakes. The consideration of error producing conditions and latent failures also revealed useful contributing factors. Human error theory offers a new and valuable way of understanding non-adherence, and could inform interventions. However, the theory needs further development to explain intentional non-adherence.

Analysis of gross error rates in operation of commercial nuclear power stations

International Nuclear Information System (INIS)

Joos, D.W.; Sabri, Z.A.; Husseiny, A.A.

1979-01-01

Experience in operation of US commercial nuclear power plants is reviewed over a 25-month period. The reports accumulated in that period on events of human error and component failure are examined to evaluate gross operator error rates. The impact of such errors on plant operation and safety is examined through the use of proper taxonomies of error, tasks and failures. Four categories of human errors are considered; namely, operator, maintenance, installation and administrative. The computed error rates are used to examine appropriate operator models for evaluation of operator reliability. Human error rates are found to be significant to a varying degree in both BWR and PWR. This emphasizes the import of considering human factors in safety and reliability analysis of nuclear systems. The results also indicate that human errors, and especially operator errors, do indeed follow the exponential reliability model. (Auth.)

Human errors in operation - what to do with them?

International Nuclear Information System (INIS)

Michalek, J.

2009-01-01

'It is human to make errors!' This saying of our predecessors is still current and will continue to be valid also in the future, until human is a human. Errors cannot be completely eliminated from human activities. In average human makes two simple errors in one hour. For example, how many typing errors do we make while typing on the computer keyboard? How many times we make mistakes in writing the date in the first days of a new year? These errors have no major consequences, however, in certain situations errors of humans are very unpleasant and may be also very costly, they may even endanger human lives. (author)

Operator error and emotions. Operator error and emotions - a major cause of human failure

International Nuclear Information System (INIS)

Patterson, B.K.; Bradley, M.; Artiss, W.G.

2000-01-01

This paper proposes the idea that a large proportion of the incidents attributed to operator and maintenance error in a nuclear or industrial plant are actually founded in our human emotions. Basic psychological theory of emotions is briefly presented and then the authors present situations and instances that can cause emotions to swell and lead to operator and maintenance error. Since emotional information is not recorded in industrial incident reports, the challenge is extended to industry, to review incident source documents for cases of emotional involvement and to develop means to collect emotion related information in future root cause analysis investigations. Training must then be provided to operators and maintainers to enable them to know one's emotions, manage emotions, motivate one's self, recognize emotions in others and handle relationships. Effective training will reduce the instances of human error based in emotions and enable a cooperative, productive environment in which to work. (author)

Operator error and emotions. Operator error and emotions - a major cause of human failure

Energy Technology Data Exchange (ETDEWEB)

Patterson, B.K. [Human Factors Practical Incorporated (Canada); Bradley, M. [Univ. of New Brunswick, Saint John, New Brunswick (Canada); Artiss, W.G. [Human Factors Practical (Canada)

2000-07-01

This paper proposes the idea that a large proportion of the incidents attributed to operator and maintenance error in a nuclear or industrial plant are actually founded in our human emotions. Basic psychological theory of emotions is briefly presented and then the authors present situations and instances that can cause emotions to swell and lead to operator and maintenance error. Since emotional information is not recorded in industrial incident reports, the challenge is extended to industry, to review incident source documents for cases of emotional involvement and to develop means to collect emotion related information in future root cause analysis investigations. Training must then be provided to operators and maintainers to enable them to know one's emotions, manage emotions, motivate one's self, recognize emotions in others and handle relationships. Effective training will reduce the instances of human error based in emotions and enable a cooperative, productive environment in which to work. (author)

Human error in strabismus surgery : Quantification with a sensitivity analysis

NARCIS (Netherlands)

Schutte, S.; Polling, J.R.; Van der Helm, F.C.T.; Simonsz, H.J.

2008-01-01

Background- Reoperations are frequently necessary in strabismus surgery. The goal of this study was to analyze human-error related factors that introduce variability in the results of strabismus surgery in a systematic fashion. Methods- We identified the primary factors that influence the outcome of

Web-Based Information Management System for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

National Research Council Canada - National Science Library

Boex, Anthony

2001-01-01

.... The Human Factors Analysis and Classification System-Maintenance Extension (HFACS-ME) taxonomy, a framework for classifying and analyzing the presence of maintenance errors that lead to mishaps, is the foundation of this tool...

Results of a nuclear power plant Application of a new technique for human error analysis (ATHEANA)

International Nuclear Information System (INIS)

Forester, J.A.; Whitehead, D.W.; Kolaczkowski, A.M.; Thompson, C.M.

1997-01-01

A new method to analyze human errors has been demonstrated at a pressurized water reactor (PWR) nuclear power plant. This was the first application of the new method referred to as A Technique for Human Error Analysis (ATHEANA). The main goals of the demonstration were to test the ATHEANA process as described in the frame-of-reference manual and the implementation guideline, test a training package developed for the method, test the hypothesis that plant operators and trainers have significant insight into the error-forcing-contexts (EFCs) that can make unsafe actions (UAs) more likely, and to identify ways to improve the method and its documentation. A set of criteria to evaluate the open-quotes successclose quotes of the ATHEANA method as used in the demonstration was identified. A human reliability analysis (HRA) team was formed that consisted of an expert in probabilistic risk assessment (PRA) with some background in HRA (not ATHEANA) and four personnel from the nuclear power plant. Personnel from the plant included two individuals from their PRA staff and two individuals from their training staff. Both individuals from training are currently licensed operators and one of them was a senior reactor operator open-quotes on shiftclose quotes until a few months before the demonstration. The demonstration was conducted over a 5 month period and was observed by members of the Nuclear Regulatory Commission's ATHEANA development team, who also served as consultants to the HRA team when necessary. Example results of the demonstration to date, including identified human failure events (HFEs), UAs, and EFCs are discussed. Also addressed is how simulator exercises are used in the ATHEANA demonstration project

Quantification of human error and common-mode failures in man-machine systems

International Nuclear Information System (INIS)

Lisboa, J.J.

1988-01-01

Quantification of human performance, particularly the determination of human error, is essential for realistic assessment of overall system performance of man-machine systems. This paper presents an analysis of human errors in nuclear power plant systems when measured against common-mode failures (CMF). Human errors evaluated are improper testing, inadequate maintenance strategy, and miscalibration. The methodology presented in the paper represents a positive contribution to power plant systems availability by identifying sources of common-mode failure when operational functions are involved. It is also applicable to other complex systems such as chemical plants, aircraft and motor industries; in fact, any large man-created, man-machine system could be included

SHERPA: A systematic human error reduction and prediction approach

International Nuclear Information System (INIS)

Embrey, D.E.

1986-01-01

This paper describes a Systematic Human Error Reduction and Prediction Approach (SHERPA) which is intended to provide guidelines for human error reduction and quantification in a wide range of human-machine systems. The approach utilizes as its basic current cognitive models of human performance. The first module in SHERPA performs task and human error analyses, which identify likely error modes, together with guidelines for the reduction of these errors by training, procedures and equipment redesign. The second module uses a SARAH approach to quantify the probability of occurrence of the errors identified earlier, and provides cost benefit analyses to assist in choosing the appropriate error reduction approaches in the third module

Human Error and Organizational Management

Directory of Open Access Journals (Sweden)

Alecxandrina DEACONU

2009-01-01

Full Text Available The concern for performance is a topic that raises interest in the businessenvironment but also in other areas that – even if they seem distant from thisworld – are aware of, interested in or conditioned by the economy development.As individual performance is very much influenced by the human resource, wechose to analyze in this paper the mechanisms that generate – consciously or not–human error nowadays.Moreover, the extremely tense Romanian context,where failure is rather a rule than an exception, made us investigate thephenomenon of generating a human error and the ways to diminish its effects.

Exploring human error in military aviation flight safety events using post-incident classification systems.

Science.gov (United States)

Hooper, Brionny J; O'Hare, David P A

2013-08-01

Human error classification systems theoretically allow researchers to analyze postaccident data in an objective and consistent manner. The Human Factors Analysis and Classification System (HFACS) framework is one such practical analysis tool that has been widely used to classify human error in aviation. The Cognitive Error Taxonomy (CET) is another. It has been postulated that the focus on interrelationships within HFACS can facilitate the identification of the underlying causes of pilot error. The CET provides increased granularity at the level of unsafe acts. The aim was to analyze the influence of factors at higher organizational levels on the unsafe acts of front-line operators and to compare the errors of fixed-wing and rotary-wing operations. This study analyzed 288 aircraft incidents involving human error from an Australasian military organization occurring between 2001 and 2008. Action errors accounted for almost twice (44%) the proportion of rotary wing compared to fixed wing (23%) incidents. Both classificatory systems showed significant relationships between precursor factors such as the physical environment, mental and physiological states, crew resource management, training and personal readiness, and skill-based, but not decision-based, acts. The CET analysis showed different predisposing factors for different aspects of skill-based behaviors. Skill-based errors in military operations are more prevalent in rotary wing incidents and are related to higher level supervisory processes in the organization. The Cognitive Error Taxonomy provides increased granularity to HFACS analyses of unsafe acts.

The action characterization matrix: A link between HERA (Human Events Reference for ATHEANA) and ATHEANA (a technique for human error analysis)

International Nuclear Information System (INIS)

Hahn, H.A.

1997-01-01

The Technique for Human Error Analysis (ATHEANA) is a newly developed human reliability analysis (HRA) methodology that aims to facilitate better representation and integration of human performance into probabilistic risk assessment (PRA) modeling and quantification by analyzing risk-significant operating experience in the context of existing behavior science models. The fundamental premise of ATHEANA is that error-forcing contexts (EFCs), which refer to combinations of equipment/material conditions and performance shaping factors (PSFs), set up or create the conditions under which unsafe actions (UAs) can occur. ATHEANA is being developed in the context of nuclear power plant (NPP) PRAs, and much of the language used to describe the method and provide examples of its application are specific to that industry. Because ATHEANA relies heavily on the analysis of operational events that have already occurred as a mechanism for generating creative thinking about possible EFCs, a database, called the Human Events Reference for ATHEANA (HERA), has been developed to support the methodology. Los Alamos National Laboratory's (LANL) Human Factors Group has recently joined the ATHEANA project team; LANL is responsible for further developing the database structure and for analyzing additional exemplar operational events for entry into the database. The Action Characterization Matrix (ACM) is conceived as a bridge between the HERA database structure and ATHEANA. Specifically, the ACM allows each unsafe action or human failure event to be characterized according to its representation along each of six different dimensions: system status, initiator status, unsafe action mechanism, information processing stage, equipment/material conditions, and performance shaping factors. This report describes the development of the ACM and provides details on the structure and content of its dimensions

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-01

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants

Analysis of Task Types and Error Types of the Human Actions Involved in the Human-related Unplanned Reactor Trip Events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun; Jung, Won Dea

2008-02-15

This report provides the task types and error types involved in the unplanned reactor trip events that have occurred during 1986 - 2006. The events that were caused by the secondary system of the nuclear power plants amount to 67 %, and the remaining 33 % was by the primary system. The contribution of the activities of the plant personnel was identified as the following order: corrective maintenance (25.7 %), planned maintenance (22.8 %), planned operation (19.8 %), periodic preventive maintenance (14.9 %), response to a transient (9.9 %), and design/manufacturing/installation (9.9%). According to the analysis of error modes, the error modes such as control failure (22.2 %), wrong object (18.5 %), omission (14.8 %), wrong action (11.1 %), and inadequate (8.3 %) take up about 75 % of all the unplanned trip events. The analysis of the cognitive functions involved showed that the planning function makes the highest contribution to the human actions leading to unplanned reactor trips, and it is followed by the observation function (23.4%), the execution function (17.8 %), and the interpretation function (10.3 %). The results of this report are to be used as important bases for development of the error reduction measures or development of the error mode prediction system for the test and maintenance tasks in nuclear power plants.

An Estimation of Human Error Probability of Filtered Containment Venting System Using Dynamic HRA Method

Energy Technology Data Exchange (ETDEWEB)

Jang, Seunghyun; Jae, Moosung [Hanyang University, Seoul (Korea, Republic of)

2016-10-15

The human failure events (HFEs) are considered in the development of system fault trees as well as accident sequence event trees in part of Probabilistic Safety Assessment (PSA). As a method for analyzing the human error, several methods, such as Technique for Human Error Rate Prediction (THERP), Human Cognitive Reliability (HCR), and Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) are used and new methods for human reliability analysis (HRA) are under developing at this time. This paper presents a dynamic HRA method for assessing the human failure events and estimation of human error probability for filtered containment venting system (FCVS) is performed. The action associated with implementation of the containment venting during a station blackout sequence is used as an example. In this report, dynamic HRA method was used to analyze FCVS-related operator action. The distributions of the required time and the available time were developed by MAAP code and LHS sampling. Though the numerical calculations given here are only for illustrative purpose, the dynamic HRA method can be useful tools to estimate the human error estimation and it can be applied to any kind of the operator actions, including the severe accident management strategy.

Human error probability estimation using licensee event reports

International Nuclear Information System (INIS)

Voska, K.J.; O'Brien, J.N.

1984-07-01

Objective of this report is to present a method for using field data from nuclear power plants to estimate human error probabilities (HEPs). These HEPs are then used in probabilistic risk activities. This method of estimating HEPs is one of four being pursued in NRC-sponsored research. The other three are structured expert judgment, analysis of training simulator data, and performance modeling. The type of field data analyzed in this report is from Licensee Event reports (LERs) which are analyzed using a method specifically developed for that purpose. However, any type of field data or human errors could be analyzed using this method with minor adjustments. This report assesses the practicality, acceptability, and usefulness of estimating HEPs from LERs and comprehensively presents the method for use

The analysis of human error as causes in the maintenance of machines: a case study in mining companies

Directory of Open Access Journals (Sweden)

Kovacevic, Srdja

2016-12-01

Full Text Available This paper describes the two-step method used to analyse the factors and aspects influencing human error during the maintenance of mining machines. The first step is the cause-effect analysis, supported by brainstorming, where five factors and 21 aspects are identified. During the second step, the group fuzzy analytic hierarchy process is used to rank the identified factors and aspects. A case study is done on mining companies in Serbia. The key aspects are ranked according to an analysis that included experts who assess risks in mining companies (a maintenance engineer, a technologist, an ergonomist, a psychologist, and an organisational scientist. Failure to follow technical maintenance instructions, poor organisation of the training process, inadequate diagnostic equipment, and a lack of understanding of the work process are identified as the most important causes of human error.

Quantitative developments in the cognitive reliability and error analysis method (CREAM) for the assessment of human performance

International Nuclear Information System (INIS)

Marseguerra, Marzio; Zio, Enrico; Librizzi, Massimo

2006-01-01

The current 'second generation' approaches in human reliability analysis focus their attention on the contextual conditions under which a given action is performed rather than on the notion of inherent human error probabilities, as was done in the earlier 'first generation' techniques. Among the 'second generation' methods, this paper considers the Cognitive Reliability and Error Analysis Method (CREAM) and proposes some developments with respect to a systematic procedure for computing probabilities of action failure. The starting point for the quantification is a previously introduced fuzzy version of the CREAM paradigm which is here further extended to include uncertainty on the qualification of the conditions under which the action is performed and to account for the fact that the effects of the common performance conditions (CPCs) on performance reliability may not all be equal. By the proposed approach, the probability of action failure is estimated by rating the performance conditions in terms of their effect on the action

The probability and the management of human error

International Nuclear Information System (INIS)

Dufey, R.B.; Saull, J.W.

2004-01-01

Embedded within modern technological systems, human error is the largest, and indeed dominant contributor to accident cause. The consequences dominate the risk profiles for nuclear power and for many other technologies. We need to quantify the probability of human error for the system as an integral contribution within the overall system failure, as it is generally not separable or predictable for actual events. We also need to provide a means to manage and effectively reduce the failure (error) rate. The fact that humans learn from their mistakes allows a new determination of the dynamic probability and human failure (error) rate in technological systems. The result is consistent with and derived from the available world data for modern technological systems. Comparisons are made to actual data from large technological systems and recent catastrophes. Best estimate values and relationships can be derived for both the human error rate, and for the probability. We describe the potential for new approaches to the management of human error and safety indicators, based on the principles of error state exclusion and of the systematic effect of learning. A new equation is given for the probability of human error (λ) that combines the influences of early inexperience, learning from experience (ε) and stochastic occurrences with having a finite minimum rate, this equation is λ 5.10 -5 + ((1/ε) - 5.10 -5 ) exp(-3*ε). The future failure rate is entirely determined by the experience: thus the past defines the future

Intervention strategies for the management of human error

Science.gov (United States)

Wiener, Earl L.

1993-01-01

This report examines the management of human error in the cockpit. The principles probably apply as well to other applications in the aviation realm (e.g. air traffic control, dispatch, weather, etc.) as well as other high-risk systems outside of aviation (e.g. shipping, high-technology medical procedures, military operations, nuclear power production). Management of human error is distinguished from error prevention. It is a more encompassing term, which includes not only the prevention of error, but also a means of disallowing an error, once made, from adversely affecting system output. Such techniques include: traditional human factors engineering, improvement of feedback and feedforward of information from system to crew, 'error-evident' displays which make erroneous input more obvious to the crew, trapping of errors within a system, goal-sharing between humans and machines (also called 'intent-driven' systems), paperwork management, and behaviorally based approaches, including procedures, standardization, checklist design, training, cockpit resource management, etc. Fifteen guidelines for the design and implementation of intervention strategies are included.

Human error analysis project (HEAP) - The fourth pilot study: verbal data for analysis of operator performance

International Nuclear Information System (INIS)

Braarud, Per Oeyvind; Droeyvoldsmo, Asgeir; Hollnagel, Erik

1997-06-01

This report is the second report from the Pilot study No. 4 within the Human Error Analyses Project (HEAP). The overall objective of HEAP is to provide a better understanding and explicit modelling of how and why ''cognitive errors'' occur. This study investigated the contribution from different verbal data sources for analysis of control room operator's performance. Operator's concurrent verbal report, retrospective verbal report, and process expert's comments were compared for their contribution to an operator performance measure. This study looked into verbal protocols for single operator and for team. The main findings of the study were that all the three verbal data sources could be used to study performance. There was a relative high overlap between the data sources, but also a unique contribution from each source. There was a common pattern in the types of operator activities the data sources gave information about. The operator's concurrent protocol overall contained slightly more information on the operator's activities than the other two verbal sources. The study also showed that concurrent verbal protocol is feasible and useful for analysis of team's activities during a scenario. (author)

Generalizing human error rates: A taxonomic approach

International Nuclear Information System (INIS)

Buffardi, L.; Fleishman, E.; Allen, J.

1989-01-01

It is well established that human error plays a major role in malfunctioning of complex, technological systems and in accidents associated with their operation. Estimates of the rate of human error in the nuclear industry range from 20-65% of all system failures. In response to this, the Nuclear Regulatory Commission has developed a variety of techniques for estimating human error probabilities for nuclear power plant personnel. Most of these techniques require the specification of the range of human error probabilities for various tasks. Unfortunately, very little objective performance data on error probabilities exist for nuclear environments. Thus, when human reliability estimates are required, for example in computer simulation modeling of system reliability, only subjective estimates (usually based on experts' best guesses) can be provided. The objective of the current research is to provide guidelines for the selection of human error probabilities based on actual performance data taken in other complex environments and applying them to nuclear settings. A key feature of this research is the application of a comprehensive taxonomic approach to nuclear and non-nuclear tasks to evaluate their similarities and differences, thus providing a basis for generalizing human error estimates across tasks. In recent years significant developments have occurred in classifying and describing tasks. Initial goals of the current research are to: (1) identify alternative taxonomic schemes that can be applied to tasks, and (2) describe nuclear tasks in terms of these schemes. Three standardized taxonomic schemes (Ability Requirements Approach, Generalized Information-Processing Approach, Task Characteristics Approach) are identified, modified, and evaluated for their suitability in comparing nuclear and non-nuclear power plant tasks. An agenda for future research and its relevance to nuclear power plant safety is also discussed

The development of human factors technologies -The development of human behaviour analysis techniques-

Energy Technology Data Exchange (ETDEWEB)

Lee, Jung Woon; Lee, Yong Heui; Park, Keun Ok; Chun, Se Woo; Suh, Sang Moon; Park, Jae Chang [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

1995-07-01

In order to contribute to human error reduction through the studies on human-machine interaction in nuclear power plants, this project has objectives to develop SACOM(Simulation Analyzer with a Cognitive Operator Model) and techniques for human error analysis and application. In this year, we studied the followings: (1) Site investigation of operator tasks, (2) Development of operator task micro structure and revision of micro structure, (3) Development of knowledge representation software and SACOM prototype, (4) Development of performance assessment methodologies in task simulation and analysis of the effects of performance shaping factors. human error analysis and application techniques> (1) Classification of error shaping factors(ESFs) and development of software for ESF evaluation, (2) Analysis of human error occurrences and revision of analysis procedure, (3) Experiment for human error data collection using a compact nuclear simulator, (4) Development of a prototype data base system of the analyzed information on trip cases. 55 figs, 23 tabs, 33 refs. (Author).

Calculating method on human error probabilities considering influence of management and organization

International Nuclear Information System (INIS)

Gao Jia; Huang Xiangrui; Shen Zupei

1996-01-01

This paper is concerned with how management and organizational influences can be factored into quantifying human error probabilities on risk assessments, using a three-level Influence Diagram (ID) which is originally only as a tool for construction and representation of models of decision-making trees or event trees. An analytical model of human errors causation has been set up with three influence levels, introducing a method for quantification assessments (of the ID), which can be applied into quantifying probabilities) of human errors on risk assessments, especially into the quantification of complex event trees (system) as engineering decision-making analysis. A numerical case study is provided to illustrate the approach

Prediction of human errors by maladaptive changes in event-related brain networks

NARCIS (Netherlands)

Eichele, T.; Debener, S.; Calhoun, V.D.; Specht, K.; Engel, A.K.; Hugdahl, K.; Cramon, D.Y. von; Ullsperger, M.

2008-01-01

Humans engaged in monotonous tasks are susceptible to occasional errors that may lead to serious consequences, but little is known about brain activity patterns preceding errors. Using functional Mill and applying independent component analysis followed by deconvolution of hemodynamic responses, we

Derivation of main drivers affecting the possibility of human errors during low power and shutdown operation

Energy Technology Data Exchange (ETDEWEB)

Kim, Ar Ryum; Seong, Poong Hyun [KAIST, Daejeon (Korea, Republic of); Park, Jin Kyun; Kim, Jae Whan [KAERI, Daejeon (Korea, Republic of)

2016-05-15

In order to estimate the possibility of human error and identify its nature, human reliability analysis (HRA) methods have been implemented. For this, various HRA methods have been developed so far: techniques for human error rate prediction (THERP), cause based decision tree (CBDT), the cognitive reliability and error analysis method (CREAM) and so on. Most HRA methods have been developed with a focus on full power operation of NPPs even though human performance may more largely affect the safety of the system during low power and shutdown (LPSD) operation than it would when the system is in full power operation. In this regard, it is necessary to conduct a research for developing HRA method to be used in LPSD operation. For the first step of the study, main drivers which affect the possibility of human error have been developed. Drivers which are commonly called as performance shaping factors (PSFs) are aspects of the human's individual characteristics, environment, organization, or task that specifically decrements or improves human performance, thus respectively increasing or decreasing the likelihood of human errors. In order to estimate the possibility of human error and identify its nature, human reliability analysis (HRA) methods have been implemented. For this, various HRA methods have been developed so far: techniques for human error rate prediction (THERP), cause based decision tree (CBDT), the cognitive reliability and error analysis method (CREAM) and so on. Most HRA methods have been developed with a focus on full power operation of NPPs even though human performance may more largely affect the safety of the system during low power and shutdown (LPSD) operation than it would when the system is in full power operation. In this regard, it is necessary to conduct a research for developing HRA method to be used in LPSD operation. For the first step of the study, main drivers which affect the possibility of human error have been developed. Drivers

Derivation of main drivers affecting the possibility of human errors during low power and shutdown operation

International Nuclear Information System (INIS)

Kim, Ar Ryum; Seong, Poong Hyun; Park, Jin Kyun; Kim, Jae Whan

2016-01-01

In order to estimate the possibility of human error and identify its nature, human reliability analysis (HRA) methods have been implemented. For this, various HRA methods have been developed so far: techniques for human error rate prediction (THERP), cause based decision tree (CBDT), the cognitive reliability and error analysis method (CREAM) and so on. Most HRA methods have been developed with a focus on full power operation of NPPs even though human performance may more largely affect the safety of the system during low power and shutdown (LPSD) operation than it would when the system is in full power operation. In this regard, it is necessary to conduct a research for developing HRA method to be used in LPSD operation. For the first step of the study, main drivers which affect the possibility of human error have been developed. Drivers which are commonly called as performance shaping factors (PSFs) are aspects of the human's individual characteristics, environment, organization, or task that specifically decrements or improves human performance, thus respectively increasing or decreasing the likelihood of human errors. In order to estimate the possibility of human error and identify its nature, human reliability analysis (HRA) methods have been implemented. For this, various HRA methods have been developed so far: techniques for human error rate prediction (THERP), cause based decision tree (CBDT), the cognitive reliability and error analysis method (CREAM) and so on. Most HRA methods have been developed with a focus on full power operation of NPPs even though human performance may more largely affect the safety of the system during low power and shutdown (LPSD) operation than it would when the system is in full power operation. In this regard, it is necessary to conduct a research for developing HRA method to be used in LPSD operation. For the first step of the study, main drivers which affect the possibility of human error have been developed. Drivers which

Collection and classification of human error and human reliability data from Indian nuclear power plants for use in PSA

International Nuclear Information System (INIS)

Subramaniam, K.; Saraf, R.K.; Sanyasi Rao, V.V.S.; Venkat Raj, V.; Venkatraman, R.

2000-01-01

Complex systems such as NPPs involve a large number of Human Interactions (HIs) in every phase of plant operations. Human Reliability Analysis (HRA) in the context of a PSA, attempts to model the HIs and evaluate/predict their impact on safety and reliability using human error/human reliability data. A large number of HRA techniques have been developed for modelling and integrating HIs into PSA but there is a significant lack of HAR data. In the face of insufficient data, human reliability analysts have had to resort to expert judgement methods in order to extend the insufficient data sets. In this situation, the generation of data from plant operating experience assumes importance. The development of a HRA data bank for Indian nuclear power plants was therefore initiated as part of the programme of work on HRA. Later, with the establishment of the coordinated research programme (CRP) on collection of human reliability data and use in PSA by IAEA in 1994-95, the development was carried out under the aegis of the IAEA research contract No. 8239/RB. The work described in this report covers the activities of development of a data taxonomy and a human error reporting form (HERF) based on it, data structuring, review and analysis of plant event reports, collection of data on human errors, analysis of the data and calculation of human error probabilities (HEPs). Analysis of plant operating experience does yield a good amount of qualitative data but obtaining quantitative data on human reliability in the form of HEPs is seen to be more difficult. The difficulties have been highlighted and some ways to bring about improvements in the data situation have been discussed. The implementation of a data system for HRA is described and useful features that can be incorporated in future systems are also discussed. (author)

Development of an FAA-EUROCONTROL technique for the analysis of human error in ATM : final report.

Science.gov (United States)

2002-07-01

Human error has been identified as a dominant risk factor in safety-oriented industries such as air traffic control (ATC). However, little is known about the factors leading to human errors in current air traffic management (ATM) systems. The first s...

Error analysis of nuclear power plant operator cognitive behavior

International Nuclear Information System (INIS)

He Xuhong; Zhao Bingquan; Chen Yulong

2001-01-01

Nuclear power plant is a complex human-machine system integrated with many advanced machines, electron devices and automatic controls. It demands operators to have high cognitive ability and correct analysis skill. The author divides operator's cognitive process into five stages to analysis. With this cognitive model, operator's cognitive error is analysed to get the root causes and stages that error happens. The results of the analysis serve as a basis in design of control rooms and training and evaluation of operators

Basic human error probabilities in advanced MCRs when using soft control

International Nuclear Information System (INIS)

Jang, In Seok; Seong, Poong Hyun; Kang, Hyun Gook; Lee, Seung Jun

2012-01-01

In a report on one of the renowned HRA methods, Technique for Human Error Rate Prediction (THERP), it is pointed out that 'The paucity of actual data on human performance continues to be a major problem for estimating HEPs and performance times in nuclear power plant (NPP) task'. However, another critical difficulty is that most current HRA databases deal with operation in conventional type of MCRs. With the adoption of new human system interfaces that are based on computer based technologies, the operation environment of MCRs in NPPs has changed. The MCRs including these digital and computer technologies, such as large display panels, computerized procedures, soft controls, and so on, are called advanced MCRs. Because of the different interfaces, different Basic Human Error Probabilities (BHEPs) should be considered in human reliability analyses (HRAs) for advanced MCRs. This study carries out an empirical analysis of human error considering soft controls. The aim of this work is not only to compile a database using the simulator for advanced MCRs but also to compare BHEPs with those of a conventional MCR database

The contributions of human factors on human error in Malaysia aviation maintenance industries

Science.gov (United States)

Padil, H.; Said, M. N.; Azizan, A.

2018-05-01

Aviation maintenance is a multitasking activity in which individuals perform varied tasks under constant pressure to meet deadlines as well as challenging work conditions. These situational characteristics combined with human factors can lead to various types of human related errors. The primary objective of this research is to develop a structural relationship model that incorporates human factors, organizational factors, and their impact on human errors in aviation maintenance. Towards that end, a questionnaire was developed which was administered to Malaysian aviation maintenance professionals. Structural Equation Modelling (SEM) approach was used in this study utilizing AMOS software. Results showed that there were a significant relationship of human factors on human errors and were tested in the model. Human factors had a partial effect on organizational factors while organizational factors had a direct and positive impact on human errors. It was also revealed that organizational factors contributed to human errors when coupled with human factors construct. This study has contributed to the advancement of knowledge on human factors effecting safety and has provided guidelines for improving human factors performance relating to aviation maintenance activities and could be used as a reference for improving safety performance in the Malaysian aviation maintenance companies.

Comprehensive analysis of a medication dosing error related to CPOE.

Science.gov (United States)

Horsky, Jan; Kuperman, Gilad J; Patel, Vimla L

2005-01-01

This case study of a serious medication error demonstrates the necessity of a comprehensive methodology for the analysis of failures in interaction between humans and information systems. The authors used a novel approach to analyze a dosing error related to computer-based ordering of potassium chloride (KCl). The method included a chronological reconstruction of events and their interdependencies from provider order entry usage logs, semistructured interviews with involved clinicians, and interface usability inspection of the ordering system. Information collected from all sources was compared and evaluated to understand how the error evolved and propagated through the system. In this case, the error was the product of faults in interaction among human and system agents that methods limited in scope to their distinct analytical domains would not identify. The authors characterized errors in several converging aspects of the drug ordering process: confusing on-screen laboratory results review, system usability difficulties, user training problems, and suboptimal clinical system safeguards that all contributed to a serious dosing error. The results of the authors' analysis were used to formulate specific recommendations for interface layout and functionality modifications, suggest new user alerts, propose changes to user training, and address error-prone steps of the KCl ordering process to reduce the risk of future medication dosing errors.

Task types and error types involved in the human-related unplanned reactor trip events

International Nuclear Information System (INIS)

Kim, Jae Whan; Park, Jin Kyun

2008-01-01

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed

Task types and error types involved in the human-related unplanned reactor trip events

Energy Technology Data Exchange (ETDEWEB)

Kim, Jae Whan; Park, Jin Kyun [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2008-12-15

In this paper, the contribution of task types and error types involved in the human-related unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants are analysed in order to establish a strategy for reducing the human-related unplanned reactor trips. Classification systems for the task types, error modes, and cognitive functions are developed or adopted from the currently available taxonomies, and the relevant information is extracted from the event reports or judged on the basis of an event description. According to the analyses from this study, the contributions of the task types are as follows: corrective maintenance (25.7%), planned maintenance (22.8%), planned operation (19.8%), periodic preventive maintenance (14.9%), response to a transient (9.9%), and design/manufacturing/installation (6.9%). According to the analysis of the error modes, error modes such as control failure (22.2%), wrong object (18.5%), omission (14.8%), wrong action (11.1%), and inadequate (8.3%) take up about 75% of the total unplanned trip events. The analysis of the cognitive functions involved in the events indicated that the planning function had the highest contribution (46.7%) to the human actions leading to unplanned reactor trips. This analysis concludes that in order to significantly reduce human-induced or human-related unplanned reactor trips, an aide system (in support of maintenance personnel) for evaluating possible (negative) impacts of planned actions or erroneous actions as well as an appropriate human error prediction technique, should be developed.

Representation of human behaviour in probabilistic safety analysis

International Nuclear Information System (INIS)

Whittingham, R.B.

1991-01-01

This paper provides an overview of the representation of human behaviour in probabilistic safety assessment. Human performance problems which may result in errors leading to accidents are considered in terms of methods of identification using task analysis, screening analysis of critical errors, representation and quantification of human errors in fault trees and event trees and error reduction measures. (author) figs., tabs., 43 refs

Human error mode identification for NPP main control room operations using soft controls

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jaewhan; Jang, Seung-Cheol

2011-01-01

The operation environment of main control rooms (MCRs) in modern nuclear power plants (NPPs) has considerably changed over the years. Advanced MCRs, which have been designed by adapting digital and computer technologies, have simpler interfaces using large display panels, computerized displays, soft controls, computerized procedure systems, and so on. The actions for the NPP operations are performed using soft controls in advanced MCRs. Soft controls have different features from conventional controls. Operators need to navigate the screens to find indicators and controls and manipulate controls using a mouse, touch screens, and so on. Due to these different interfaces, different human errors should be considered in the human reliability analysis (HRA) for advanced MCRs. In this work, human errors that could occur during operation executions using soft controls were analyzed. This work classified the human errors in soft controls into six types, and the reasons that affect the occurrence of the human errors were also analyzed. (author)

Development of Human Factor Management Requirements and Human Error Classification for the Prevention of Railway Accident

International Nuclear Information System (INIS)

Kwak, Sang Log; Park, Chan Woo; Shin, Seung Ryoung

2008-08-01

Railway accident analysis results show that accidents cased by human factors are not decreasing, whereas H/W related accidents are steadily decreasing. For the efficient management of human factors, many expertise on design, conditions, safety culture and staffing are required. But current safety management activities on safety critical works are focused on training, due to the limited resource and information. In order to improve railway safety, human factors management requirements for safety critical worker and human error classification is proposed in this report. For this accident analysis, status of safety measure on human factor, safety management system on safety critical worker, current safety planning is analysis

Human errors in test and maintenance of nuclear power plants. Nordic project work

International Nuclear Information System (INIS)

Andersson, H.; Liwaang, B.

1985-08-01

The present report is a summary of the NKA/LIT-1 project performed for the period 1981-1985. The report summarizes work on human error influence in test and calibration activities in nuclear power plants, reviews problems regarding optimization of the test intervals, organization of test and maintenance activities, and the analysis of human error contribution to the overall risk in test and mainenace tasks. (author)

Human decision error (HUMDEE) trees

International Nuclear Information System (INIS)

Ostrom, L.T.

1993-01-01

Graphical presentations of human actions in incident and accident sequences have been used for many years. However, for the most part, human decision making has been underrepresented in these trees. This paper presents a method of incorporating the human decision process into graphical presentations of incident/accident sequences. This presentation is in the form of logic trees. These trees are called Human Decision Error Trees or HUMDEE for short. The primary benefit of HUMDEE trees is that they graphically illustrate what else the individuals involved in the event could have done to prevent either the initiation or continuation of the event. HUMDEE trees also present the alternate paths available at the operator decision points in the incident/accident sequence. This is different from the Technique for Human Error Rate Prediction (THERP) event trees. There are many uses of these trees. They can be used for incident/accident investigations to show what other courses of actions were available and for training operators. The trees also have a consequence component so that not only the decision can be explored, also the consequence of that decision

Human errors during the simulations of an SGTR scenario: Application of the HERA system

International Nuclear Information System (INIS)

Jung, Won Dea; Whaley, April M.; Hallbert, Bruce P.

2009-01-01

Due to the need of data for a Human Reliability Analysis (HRA), a number of data collection efforts have been undertaken in several different organizations. As a part of this effort, a human error analysis that focused on a set of simulator records on a Steam Generator Tube Rupture (SGTR) scenario was performed by using the Human Event Repository and Analysis (HERA) system. This paper summarizes the process and results of the HERA analysis, including discussions about the usability of the HERA system for a human error analysis of simulator data. Five simulated records of an SGTR scenario were analyzed with the HERA analysis process in order to scrutinize the causes and mechanisms of the human related events. From this study, the authors confirmed that the HERA was a serviceable system that can analyze human performance qualitatively from simulator data. It was possible to identify the human related events in the simulator data that affected the system safety not only negatively but also positively. It was also possible to scrutinize the Performance Shaping Factors (PSFs) and the relevant contributory factors with regard to each identified human event

Trend analysis and comparison of operators' human error events occurred at overseas and domestic nuclear power plants

International Nuclear Information System (INIS)

Takagawa, Kenichi

2006-01-01

Human errors by operators at overseas and domestic nuclear power plants during the period from 2002 to 2005 were compared and their trends analyzed. The most frequently cited cause of such errors was 'insufficient team monitoring' (inadequate superiors' and other crews' instructions and supervision) both at overseas and domestic plants, followed by 'insufficient self-checking' (lack of cautions by the operator himself). A comparison of the effects of the errors on the operations of plants in Japan and the United Sates showed that the drop in plant output and plant shutdowns at plants in Japan were approximately one-tenth of those in the United States. The ratio of automatic reactor trips to the total number of human errors reported is about 6% for both Japanese and American plants. Looking at changes in the incidence of human errors by years of occurrence, although a distinctive trend cannot be identified for domestic nuclear power plants due to insufficient reported cases, 'inadequate self-checking' as a factor contributing to human errors at overseas nuclear power plants has decreased significantly over the past four years. Regarding changes in the effects of human errors on the operations of plants during the four-year period, events leading to an automatic reactor trip have tended to increase at American plants. Conceivable factors behind this increasing tendency included lack of operating experience by a team (e.g., plant transients and reactor shutdowns and startups) and excessive dependence on training simulators. (author)

An empirical study on the human error recovery failure probability when using soft controls in NPP advanced MCRs

International Nuclear Information System (INIS)

Jang, Inseok; Kim, Ar Ryum; Jung, Wondea; Seong, Poong Hyun

2014-01-01

Highlights: • Many researchers have tried to understand human recovery process or step. • Modeling human recovery process is not sufficient to be applied to HRA. • The operation environment of MCRs in NPPs has changed by adopting new HSIs. • Recovery failure probability in a soft control operation environment is investigated. • Recovery failure probability here would be important evidence for expert judgment. - Abstract: It is well known that probabilistic safety assessments (PSAs) today consider not just hardware failures and environmental events that can impact upon risk, but also human error contributions. Consequently, the focus on reliability and performance management has been on the prevention of human errors and failures rather than the recovery of human errors. However, the recovery of human errors is as important as the prevention of human errors and failures for the safe operation of nuclear power plants (NPPs). For this reason, many researchers have tried to find a human recovery process or step. However, modeling the human recovery process is not sufficient enough to be applied to human reliability analysis (HRA), which requires human error and recovery probabilities. In this study, therefore, human error recovery failure probabilities based on predefined human error modes were investigated by conducting experiments in the operation mockup of advanced/digital main control rooms (MCRs) in NPPs. To this end, 48 subjects majoring in nuclear engineering participated in the experiments. In the experiments, using the developed accident scenario based on tasks from the standard post trip action (SPTA), the steam generator tube rupture (SGTR), and predominant soft control tasks, which are derived from the loss of coolant accident (LOCA) and the excess steam demand event (ESDE), all error detection and recovery data based on human error modes were checked with the performance sheet and the statistical analysis of error recovery/detection was then

Human Error Mechanisms in Complex Work Environments

DEFF Research Database (Denmark)

Rasmussen, Jens

1988-01-01

will account for most of the action errors observed. In addition, error mechanisms appear to be intimately related to the development of high skill and know-how in a complex work context. This relationship between errors and human adaptation is discussed in detail for individuals and organisations...

Human error prediction and countermeasures based on CREAM in spent nuclear fuel (SNF) transportation

International Nuclear Information System (INIS)

Kim, Jae San

2007-02-01

Since the 1980s, in order to secure the storage capacity of spent nuclear fuel (SNF) at NPPs, SNF assemblies have been transported on-site from one unit to another unit nearby. However in the future the amount of the spent fuel will approach capacity in the areas used, and some of these SNFs will have to be transported to an off-site spent fuel repository. Most SNF materials used at NPPs will be transported by general cargo ships from abroad, and these SNFs will be stored in an interim storage facility. In the process of transporting SNF, human interactions will involve inspecting and preparing the cask and spent fuel, loading the cask onto the vehicle or ship, transferring the cask as well as storage or monitoring the cask. The transportation of SNF involves a number of activities that depend on reliable human performance. In the case of the transport of a cask, human errors may include spent fuel bundle misidentification or cask transport accidents among others. Reviews of accident events when transporting the Radioactive Material (RAM) throughout the world indicate that human error is the major causes for more than 65% of significant events. For the safety of SNF transportation, it is very important to predict human error and to deduce a method that minimizes the human error. This study examines the human factor effects on the safety of transporting spent nuclear fuel (SNF). It predicts and identifies the possible human errors in the SNF transport process (loading, transfer and storage of the SNF). After evaluating the human error mode in each transport process, countermeasures to minimize the human error are deduced. The human errors in SNF transportation were analyzed using Hollnagel's Cognitive Reliability and Error Analysis Method (CREAM). After determining the important factors for each process, countermeasures to minimize human error are provided in three parts: System design, Operational environment, and Human ability

Effects of digital human-machine interface characteristics on human error in nuclear power plants

International Nuclear Information System (INIS)

Li Pengcheng; Zhang Li; Dai Licao; Huang Weigang

2011-01-01

In order to identify the effects of digital human-machine interface characteristics on human error in nuclear power plants, the new characteristics of digital human-machine interface are identified by comparing with the traditional analog control systems in the aspects of the information display, user interface interaction and management, control systems, alarm systems and procedures system, and the negative effects of digital human-machine interface characteristics on human error are identified by field research and interviewing with operators such as increased cognitive load and workload, mode confusion, loss of situation awareness. As to the adverse effects related above, the corresponding prevention and control measures of human errors are provided to support the prevention and minimization of human errors and the optimization of human-machine interface design. (authors)

The development of human factors technologies -The development of human behaviour analysis techniques-

International Nuclear Information System (INIS)

Lee, Jung Woon; Lee, Yong Heui; Park, Keun Ok; Chun, Se Woo; Suh, Sang Moon; Park, Jae Chang

1995-07-01

In order to contribute to human error reduction through the studies on human-machine interaction in nuclear power plants, this project has objectives to develop SACOM(Simulation Analyzer with a Cognitive Operator Model) and techniques for human error analysis and application. In this year, we studied the followings: 1) Site investigation of operator tasks, 2) Development of operator task micro structure and revision of micro structure, 3) Development of knowledge representation software and SACOM prototype, 4) Development of performance assessment methodologies in task simulation and analysis of the effects of performance shaping factors. 1) Classification of error shaping factors(ESFs) and development of software for ESF evaluation, 2) Analysis of human error occurrences and revision of analysis procedure, 3) Experiment for human error data collection using a compact nuclear simulator, 4) Development of a prototype data base system of the analyzed information on trip cases. 55 figs, 23 tabs, 33 refs. (Author)

Uncertainty quantification and error analysis

Energy Technology Data Exchange (ETDEWEB)

Higdon, Dave M [Los Alamos National Laboratory; Anderson, Mark C [Los Alamos National Laboratory; Habib, Salman [Los Alamos National Laboratory; Klein, Richard [Los Alamos National Laboratory; Berliner, Mark [OHIO STATE UNIV.; Covey, Curt [LLNL; Ghattas, Omar [UNIV OF TEXAS; Graziani, Carlo [UNIV OF CHICAGO; Seager, Mark [LLNL; Sefcik, Joseph [LLNL; Stark, Philip [UC/BERKELEY; Stewart, James [SNL

2010-01-01

UQ studies all sources of error and uncertainty, including: systematic and stochastic measurement error; ignorance; limitations of theoretical models; limitations of numerical representations of those models; limitations on the accuracy and reliability of computations, approximations, and algorithms; and human error. A more precise definition for UQ is suggested below.

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon [KAERI, Daejeon (Korea, Republic of)

2012-10-15

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail.

Investigations on human error hazards in recent unintended trip events of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Jang, Tong Il; Lee, Yong Hee; Shin, Kwang Hyeon

2012-01-01

According to the Operational Performance Information System (OPIS) which has been operated to improve the public understanding by the KINS (Korea Institute of Nuclear Safety), unintended trip events by mainly human errors counted up to 38 cases (18.7%) from 2000 to 2011. Although the Nuclear Power Plant (NPP) industry in Korea has been making efforts to reduce the human errors which have largely contributed to trip events, the human error rate might keep increasing. Interestingly, digital based I and C systems is the one of the reduction factors of unintended reactor trips. Human errors, however, have occurred due to the digital based I and C systems because those systems require new or changed behaviors to the NPP operators. Therefore, it is necessary that the investigations of human errors consider a new methodology to find not only tangible behavior but also intangible behavior such as organizational behaviors. In this study we investigated human errors to find latent factors such as decisions and conditions in the all of the unintended reactor trip events during last dozen years. To find them, we applied the HFACS (Human Factors Analysis and Classification System) which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. The objective of this study is to find latent factors behind of human errors in nuclear reactor trip events. Therefore, a method to investigate unintended trip events by human errors and the results will be discussed in more detail

Human factors interventions to reduce human errors and improve productivity in maintenance tasks

International Nuclear Information System (INIS)

Isoda, Hachiro; Yasutake, J.Y.

1992-01-01

This paper describes work in progress to develop interventions to reduce human errors and increase maintenance productivity in nuclear power plants. The effort is part of a two-phased Human Factors research program being conducted jointly by the Central Research Institute of Electric Power Industry (CRIEPI) in Japan and the Electric Power Research Institute (EPRI) in the United States. The overall objective of this joint research program is to identify critical maintenance tasks and to develop, implement and evaluate interventions which have high potential for reducing human errors or increasing maintenance productivity. As a result of the Phase 1 effort, ten critical maintenance tasks were identified. For these tasks, over 25 candidate interventions were identified for potential development. After careful analysis, seven interventions were selected for development during Phase 2. This paper describes the methodology used to analyze and identify the most critical tasks, the process of identifying and developing selected interventions and some of the initial results. (author)

Human error theory: relevance to nurse management.

Science.gov (United States)

Armitage, Gerry

2009-03-01

Describe, discuss and critically appraise human error theory and consider its relevance for nurse managers. Healthcare errors are a persistent threat to patient safety. Effective risk management and clinical governance depends on understanding the nature of error. This paper draws upon a wide literature from published works, largely from the field of cognitive psychology and human factors. Although the content of this paper is pertinent to any healthcare professional; it is written primarily for nurse managers. Error is inevitable. Causation is often attributed to individuals, yet causation in complex environments such as healthcare is predominantly multi-factorial. Individual performance is affected by the tendency to develop prepacked solutions and attention deficits, which can in turn be related to local conditions and systems or latent failures. Blame is often inappropriate. Defences should be constructed in the light of these considerations and to promote error wisdom and organizational resilience. Managing and learning from error is seen as a priority in the British National Health Service (NHS), this can be better achieved with an understanding of the roots, nature and consequences of error. Such an understanding can provide a helpful framework for a range of risk management activities.

Applying lessons learned to enhance human performance and reduce human error for ISS operations

Energy Technology Data Exchange (ETDEWEB)

Nelson, W.R.

1998-09-01

A major component of reliability, safety, and mission success for space missions is ensuring that the humans involved (flight crew, ground crew, mission control, etc.) perform their tasks and functions as required. This includes compliance with training and procedures during normal conditions, and successful compensation when malfunctions or unexpected conditions occur. A very significant issue that affects human performance in space flight is human error. Human errors can invalidate carefully designed equipment and procedures. If certain errors combine with equipment failures or design flaws, mission failure or loss of life can occur. The control of human error during operation of the International Space Station (ISS) will be critical to the overall success of the program. As experience from Mir operations has shown, human performance plays a vital role in the success or failure of long duration space missions. The Department of Energy`s Idaho National Engineering and Environmental Laboratory (INEEL) is developed a systematic approach to enhance human performance and reduce human errors for ISS operations. This approach is based on the systematic identification and evaluation of lessons learned from past space missions such as Mir to enhance the design and operation of ISS. This paper describes previous INEEL research on human error sponsored by NASA and how it can be applied to enhance human reliability for ISS.

Risk Management and the Concept of Human Error

DEFF Research Database (Denmark)

Rasmussen, Jens

1995-01-01

by a stochastic coincidence of faults and human errors, but by a systemic erosion of the defenses due to decision making under competitive pressure in a dynamic environment. The presentation will discuss the nature of human error and the risk management problems found in a dynamic, competitive society facing...

Selection of anchor values for human error probability estimation

International Nuclear Information System (INIS)

Buffardi, L.C.; Fleishman, E.A.; Allen, J.A.

1989-01-01

There is a need for more dependable information to assist in the prediction of human errors in nuclear power environments. The major objective of the current project is to establish guidelines for using error probabilities from other task settings to estimate errors in the nuclear environment. This involves: (1) identifying critical nuclear tasks, (2) discovering similar tasks in non-nuclear environments, (3) finding error data for non-nuclear tasks, and (4) establishing error-rate values for the nuclear tasks based on the non-nuclear data. A key feature is the application of a classification system to nuclear and non-nuclear tasks to evaluate their similarities and differences in order to provide a basis for generalizing human error estimates across tasks. During the first eight months of the project, several classification systems have been applied to a sample of nuclear tasks. They are discussed in terms of their potential for establishing task equivalence and transferability of human error rates across situations

Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS

National Research Council Canada - National Science Library

Wiegmann, Douglas; Faaborg, Troy; Boquet, Albert; Detwiler, Cristy; Holcomb, Kali; Shappell, Scott

2005-01-01

... of both commercial and general aviation (GA) accidents. These analyses have helped to identify general trends in the types of human factors issues and aircrew errors that have contributed to civil aviation accidents...

Basic considerations in predicting error probabilities in human task performance

International Nuclear Information System (INIS)

Fleishman, E.A.; Buffardi, L.C.; Allen, J.A.; Gaskins, R.C. III

1990-04-01

It is well established that human error plays a major role in the malfunctioning of complex systems. This report takes a broad look at the study of human error and addresses the conceptual, methodological, and measurement issues involved in defining and describing errors in complex systems. In addition, a review of existing sources of human reliability data and approaches to human performance data base development is presented. Alternative task taxonomies, which are promising for establishing the comparability on nuclear and non-nuclear tasks, are also identified. Based on such taxonomic schemes, various data base prototypes for generalizing human error rates across settings are proposed. 60 refs., 3 figs., 7 tabs

A chance to avoid mistakes human error

International Nuclear Information System (INIS)

Amaro, Pablo; Obeso, Eduardo; Gomez, Ruben

2010-01-01

Trying to give an answer to the lack of public information in the industry, in relationship with the different tools that are managed in the nuclear industry for minimizing the human error, a group of workers from different sections of the St. Maria de Garona NPP (Quality Assurance/ Organization and Human Factors) decided to embark on a challenging and exciting project: 'Write a book collecting all the knowledge accumulated during their daily activities, very often during lecture time of external information received from different organizations within the nuclear industry (INPO, WANO...), but also visiting different NPP's, maintaining meetings and participating in training courses related de Human and Organizational Factors'. Main objective of the book is presenting to the industry in general, the different tools that are used and fostered in the nuclear industry, in a practical way. In this way, the assimilation and implementation in others industries could be possible and achievable in and efficient context. One year of work, and our project is a reality. We have presented and abstract during the last Spanish Nuclear Society meeting in Sevilla, last October...and the best, the book is into the market for everybody in web-site: www.bubok.com. The book is structured in the following areas: 'Errare humanum est': Trying to present what is the human error to the reader, its origin and the different barriers. The message is that the reader see the error like something continuously present in our lives... even more frequently than we think. Studying its origin can be established aimed at barriers to avoid or at least minimize it. 'Error's bitter face': Shows the possible consequences of human errors. What better that presenting real experiences that have occurred in the industry. In the book, accidents in the nuclear industry, like Tree Mile Island NPP, Chernobyl NPP, and incidents like Davis Besse NPP in the past, helps to the reader to make a reflection about the

Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant

Directory of Open Access Journals (Sweden)

Mehdi Jahangiri

2016-03-01

Conclusion: The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided.

Nursing Errors in Intensive Care Unit by Human Error Identification in Systems Tool: A Case Study

Directory of Open Access Journals (Sweden)

Nezamodini

2016-03-01

Full Text Available Background Although health services are designed and implemented to improve human health, the errors in health services are a very common phenomenon and even sometimes fatal in this field. Medical errors and their cost are global issues with serious consequences for the patients’ community that are preventable and require serious attention. Objectives The current study aimed to identify possible nursing errors applying human error identification in systems tool (HEIST in the intensive care units (ICUs of hospitals. Patients and Methods This descriptive research was conducted in the intensive care unit of a hospital in Khuzestan province in 2013. Data were collected through observation and interview by nine nurses in this section in a period of four months. Human error classification was based on Rose and Rose and Swain and Guttmann models. According to HEIST work sheets the guide questions were answered and error causes were identified after the determination of the type of errors. Results In total 527 errors were detected. The performing operation on the wrong path had the highest frequency which was 150, and the second rate with a frequency of 136 was doing the tasks later than the deadline. Management causes with a frequency of 451 were the first rank among identified errors. Errors mostly occurred in the system observation stage and among the performance shaping factors (PSFs, time was the most influencing factor in occurrence of human errors. Conclusions Finally, in order to prevent the occurrence and reduce the consequences of identified errors the following suggestions were proposed : appropriate training courses, applying work guidelines and monitoring their implementation, increasing the number of work shifts, hiring professional workforce, equipping work space with appropriate facilities and equipment.

Human error recovery failure probability when using soft controls in computerized control rooms

International Nuclear Information System (INIS)

Jang, Inseok; Kim, Ar Ryum; Seong, Poong Hyun; Jung, Wondea

2014-01-01

Many literatures categorized recovery process into three phases; detection of problem situation, explanation of problem causes or countermeasures against problem, and end of recovery. Although the focus of recovery promotion has been on categorizing recovery phases and modeling recovery process, research related to human recovery failure probabilities has not been perform actively. On the other hand, a few study regarding recovery failure probabilities were implemented empirically. Summarizing, researches that have performed so far have several problems in terms of use in human reliability analysis (HRA). By adopting new human-system interfaces that are based on computer-based technologies, the operation environment of MCRs in NPPs has changed from conventional MCRs to advanced MCRs. Because of the different interfaces between conventional and advanced MCRs, different recovery failure probabilities should be considered in the HRA for advanced MCRs. Therefore, this study carries out an empirical analysis of human error recovery probabilities under an advanced MCR mockup called compact nuclear simulator (CNS). The aim of this work is not only to compile a recovery failure probability database using the simulator for advanced MCRs but also to collect recovery failure probability according to defined human error modes to compare that which human error mode has highest recovery failure probability. The results show that recovery failure probability regarding wrong screen selection was lowest among human error modes, which means that most of human error related to wrong screen selection can be recovered. On the other hand, recovery failure probabilities of operation selection omission and delayed operation were 1.0. These results imply that once subject omitted one task in the procedure, they have difficulties finding and recovering their errors without supervisor's assistance. Also, wrong screen selection had an effect on delayed operation. That is, wrong screen

Human reliability analysis in Loviisa probabilistic safety analysis

International Nuclear Information System (INIS)

Illman, L.; Isaksson, J.; Makkonen, L.; Vaurio, J.K.; Vuorio, U.

1986-01-01

The human reliability analysis in the Loviisa PSA project is carried out for three major groups of errors in human actions: (A) errors made before an initiating event, (B) errors that initiate a transient and (C) errors made during transients. Recovery possibilities are also included in each group. The methods used or planned for each group are described. A simplified THERP approach is used for group A, with emphasis on test and maintenance error recovery aspects and dependencies between redundancies. For group B, task analyses and human factors assessments are made for startup, shutdown and operational transients, with emphasis on potential common cause initiators. For group C, both misdiagnosis and slow decision making are analyzed, as well as errors made in carrying out necessary or backup actions. New or advanced features of the methodology are described

Normalization of Deviation: Quotation Error in Human Factors.

Science.gov (United States)

Lock, Jordan; Bearman, Chris

2018-05-01

Objective The objective of this paper is to examine quotation error in human factors. Background Science progresses through building on the work of previous research. This requires accurate quotation. Quotation error has a number of adverse consequences: loss of credibility, loss of confidence in the journal, and a flawed basis for academic debate and scientific progress. Quotation error has been observed in a number of domains, including marine biology and medicine, but there has been little or no previous study of this form of error in human factors, a domain that specializes in the causes and management of error. Methods A study was conducted examining quotation accuracy of 187 extracts from 118 published articles that cited a control article (Vaughan's 1996 book: The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA). Results Of extracts studied, 12.8% ( n = 24) were classed as inaccurate, with 87.2% ( n = 163) being classed as accurate. A second dimension of agreement was examined with 96.3% ( n = 180) agreeing with the control article and only 3.7% ( n = 7) disagreeing. The categories of accuracy and agreement form a two by two matrix. Conclusion Rather than simply blaming individuals for quotation error, systemic factors should also be considered. Vaughan's theory, normalization of deviance, is one systemic theory that can account for quotation error. Application Quotation error is occurring in human factors and should receive more attention. According to Vaughan's theory, the normal everyday systems that promote scholarship may also allow mistakes, mishaps, and quotation error to occur.

BAYES-HEP: Bayesian belief networks for estimation of human error probability

International Nuclear Information System (INIS)

Karthick, M.; Senthil Kumar, C.; Paul, Robert T.

2017-01-01

Human errors contribute a significant portion of risk in safety critical applications and methods for estimation of human error probability have been a topic of research for over a decade. The scarce data available on human errors and large uncertainty involved in the prediction of human error probabilities make the task difficult. This paper presents a Bayesian belief network (BBN) model for human error probability estimation in safety critical functions of a nuclear power plant. The developed model using BBN would help to estimate HEP with limited human intervention. A step-by-step illustration of the application of the method and subsequent evaluation is provided with a relevant case study and the model is expected to provide useful insights into risk assessment studies

Thresholds for human detection of patient setup errors in digitally reconstructed portal images of prostate fields

International Nuclear Information System (INIS)

Phillips, Brooke L.; Jiroutek, Michael R.; Tracton, Gregg; Elfervig, Michelle; Muller, Keith E.; Chaney, Edward L.

2002-01-01

Purpose: Computer-assisted methods to analyze electronic portal images for the presence of treatment setup errors should be studied in controlled experiments before use in the clinical setting. Validation experiments using images that contain known errors usually report the smallest errors that can be detected by the image analysis algorithm. This paper offers human error-detection thresholds as one benchmark for evaluating the smallest errors detected by algorithms. Unfortunately, reliable data are lacking describing human performance. The most rigorous benchmarks for human performance are obtained under conditions that favor error detection. To establish such benchmarks, controlled observer studies were carried out to determine the thresholds of detectability for in-plane and out-of-plane translation and rotation setup errors introduced into digitally reconstructed portal radiographs (DRPRs) of prostate fields. Methods and Materials: Seventeen observers comprising radiation oncologists, radiation oncology residents, physicists, and therapy students participated in a two-alternative forced choice experiment involving 378 DRPRs computed using the National Library of Medicine Visible Human data sets. An observer viewed three images at a time displayed on adjacent computer monitors. Each image triplet included a reference digitally reconstructed radiograph displayed on the central monitor and two DRPRs displayed on the flanking monitors. One DRPR was error free. The other DRPR contained a known in-plane or out-of-plane error in the placement of the treatment field over a target region in the pelvis. The range for each type of error was determined from pilot observer studies based on a Probit model for error detection. The smallest errors approached the limit of human visual capability. The observer was told what kind of error was introduced, and was asked to choose the DRPR that contained the error. Observer decisions were recorded and analyzed using repeated

Human error identification for laparoscopic surgery: Development of a motion economy perspective.

Science.gov (United States)

Al-Hakim, Latif; Sevdalis, Nick; Maiping, Tanaphon; Watanachote, Damrongpan; Sengupta, Shomik; Dissaranan, Charuspong

2015-09-01

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Review of advances in human reliability analysis of errors of commission-Part 2: EOC quantification

International Nuclear Information System (INIS)

Reer, Bernhard

2008-01-01

In close connection with examples relevant to contemporary probabilistic safety assessment (PSA), a review of advances in human reliability analysis (HRA) of post-initiator errors of commission (EOCs), i.e. inappropriate actions under abnormal operating conditions, has been carried out. The review comprises both EOC identification (part 1) and quantification (part 2); part 2 is presented in this article. Emerging HRA methods in this field are: ATHEANA, MERMOS, the EOC HRA method developed by Gesellschaft fuer Anlagen- und Reaktorsicherheit (GRS), the MDTA method and CREAM. The essential advanced features are on the conceptual side, especially to envisage the modeling of multiple contexts for an EOC to be quantified (ATHEANA, MERMOS and MDTA), in order to explicitly address adverse conditions. There is promising progress in providing systematic guidance to better account for cognitive demands and tendencies (GRS, CREAM), and EOC recovery (MDTA). Problematic issues are associated with the implementation of multiple context modeling and the assessment of context-specific error probabilities. Approaches for task or error opportunity scaling (CREAM, GRS) and the concept of reference cases (ATHEANA outlook) provide promising orientations for achieving progress towards data-based quantification. Further development work is needed and should be carried out in close connection with large-scale applications of existing approaches

An empirical study on the basic human error probabilities for NPP advanced main control room operation using soft control

International Nuclear Information System (INIS)

Jang, Inseok; Kim, Ar Ryum; Harbi, Mohamed Ali Salem Al; Lee, Seung Jun; Kang, Hyun Gook; Seong, Poong Hyun

2013-01-01

Highlights: ► The operation environment of MCRs in NPPs has changed by adopting new HSIs. ► The operation action in NPP Advanced MCRs is performed by soft control. ► Different basic human error probabilities (BHEPs) should be considered. ► BHEPs in a soft control operation environment are investigated empirically. ► This work will be helpful to verify if soft control has positive or negative effects. -- Abstract: By adopting new human–system interfaces that are based on computer-based technologies, the operation environment of main control rooms (MCRs) in nuclear power plants (NPPs) has changed. The MCRs that include these digital and computer technologies, such as large display panels, computerized procedures, soft controls, and so on, are called Advanced MCRs. Among the many features in Advanced MCRs, soft controls are an important feature because the operation action in NPP Advanced MCRs is performed by soft control. Using soft controls such as mouse control, touch screens, and so on, operators can select a specific screen, then choose the controller, and finally manipulate the devices. However, because of the different interfaces between soft control and hardwired conventional type control, different basic human error probabilities (BHEPs) should be considered in the Human Reliability Analysis (HRA) for advanced MCRs. Although there are many HRA methods to assess human reliabilities, such as Technique for Human Error Rate Prediction (THERP), Accident Sequence Evaluation Program (ASEP), Human Error Assessment and Reduction Technique (HEART), Human Event Repository and Analysis (HERA), Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR), Cognitive Reliability and Error Analysis Method (CREAM), and so on, these methods have been applied to conventional MCRs, and they do not consider the new features of advance MCRs such as soft controls. As a result, there is an insufficient database for assessing human reliabilities in advanced

Automation of Commanding at NASA: Reducing Human Error in Space Flight

Science.gov (United States)

Dorn, Sarah J.

2010-01-01

Automation has been implemented in many different industries to improve efficiency and reduce human error. Reducing or eliminating the human interaction in tasks has been proven to increase productivity in manufacturing and lessen the risk of mistakes by humans in the airline industry. Human space flight requires the flight controllers to monitor multiple systems and react quickly when failures occur so NASA is interested in implementing techniques that can assist in these tasks. Using automation to control some of these responsibilities could reduce the number of errors the flight controllers encounter due to standard human error characteristics. This paper will investigate the possibility of reducing human error in the critical area of manned space flight at NASA.

Practical Insights from Initial Studies Related to Human Error Analysis Project (HEAP)

International Nuclear Information System (INIS)

Follesoe, Knut; Kaarstad, Magnhild; Droeivoldsmo, Asgeir; Hollnagel, Erik; Kirwan; Barry

1996-01-01

This report presents practical insights made from an analysis of the three initial studies in the Human Error Analysis Project (HEAP), and the first study in the US NRC Staffing Project. These practical insights relate to our understanding of diagnosis in Nuclear Power Plant (NPP) emergency scenarios and, in particular, the factors that influence whether a diagnosis will succeed or fail. The insights reported here focus on three inter-related areas: (1) the diagnostic strategies and styles that have been observed in single operator and team-based studies; (2) the qualitative aspects of the key operator support systems, namely VDU interfaces, alarms, training and procedures, that have affected the outcome of diagnosis; and (3) the overall success rates of diagnosis and the error types that have been observed in the various studies. With respect to diagnosis, certain patterns have emerged from the various studies, depending on whether operators were alone or in teams, and on their familiarity with the process. Some aspects of the interface and alarm systems were found to contribute to diagnostic failures while others supported performance and recovery. Similar results were found for training and experience. Furthermore, the availability of procedures did not preclude the need for some diagnosis. With respect to HRA and PSA, it was possible to record the failure types seen in the studies, and in some cases to give crude estimates of the failure likelihood for certain scenarios. Although these insights are interim in nature, they do show the type of information that can be derived from these studies. More importantly, they clarify aspects of our understanding of diagnosis in NPP emergencies, including implications for risk assessment, operator support systems development, and for research into diagnosis in a broader range of fields than the nuclear power industry. (author)

Risk assessment of component failure modes and human errors using a new FMECA approach: application in the safety analysis of HDR brachytherapy

International Nuclear Information System (INIS)

Giardina, M; Castiglia, F; Tomarchio, E

2014-01-01

Failure mode, effects and criticality analysis (FMECA) is a safety technique extensively used in many different industrial fields to identify and prevent potential failures. In the application of traditional FMECA, the risk priority number (RPN) is determined to rank the failure modes; however, the method has been criticised for having several weaknesses. Moreover, it is unable to adequately deal with human errors or negligence. In this paper, a new versatile fuzzy rule-based assessment model is proposed to evaluate the RPN index to rank both component failure and human error. The proposed methodology is applied to potential radiological over-exposure of patients during high-dose-rate brachytherapy treatments. The critical analysis of the results can provide recommendations and suggestions regarding safety provisions for the equipment and procedures required to reduce the occurrence of accidental events. (paper)

An Approach to Human Error Hazard Detection of Unexpected Situations in NPPs

Energy Technology Data Exchange (ETDEWEB)

Park, Sangjun; Oh, Yeonju; Shin, Youmin; Lee, Yong-Hee [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2015-10-15

Fukushima accident is a typical complex event including the extreme situations induced by the succeeding earthquake, tsunami, explosion, and human errors. And it is judged with incomplete cause of system build-up same manner, procedure as a deficiency of response manual, education and training, team capability and the discharge of operator from human engineering point of view. Especially, the guidelines of current operating NPPs are not enough including countermeasures to the human errors at the extreme situations. Therefore, this paper describes a trial to detect the hazards of human errors at extreme situation, and to define the countermeasures that can properly response to the human error hazards when an individual, team, organization, and working entities that encounter the extreme situation in NPPs. In this paper we try to propose an approach to analyzing and extracting human error hazards for suggesting additional countermeasures to the human errors in unexpected situations. They might be utilized to develop contingency guidelines, especially for reducing the human error accident in NPPs. But the trial application in this study is currently limited since it is not easy to find accidents cases in detail enough to enumerate the proposed steps. Therefore, we will try to analyze as more cases as possible, and consider other environmental factors and human error conditions.

An Approach to Human Error Hazard Detection of Unexpected Situations in NPPs

International Nuclear Information System (INIS)

Park, Sangjun; Oh, Yeonju; Shin, Youmin; Lee, Yong-Hee

2015-01-01

Fukushima accident is a typical complex event including the extreme situations induced by the succeeding earthquake, tsunami, explosion, and human errors. And it is judged with incomplete cause of system build-up same manner, procedure as a deficiency of response manual, education and training, team capability and the discharge of operator from human engineering point of view. Especially, the guidelines of current operating NPPs are not enough including countermeasures to the human errors at the extreme situations. Therefore, this paper describes a trial to detect the hazards of human errors at extreme situation, and to define the countermeasures that can properly response to the human error hazards when an individual, team, organization, and working entities that encounter the extreme situation in NPPs. In this paper we try to propose an approach to analyzing and extracting human error hazards for suggesting additional countermeasures to the human errors in unexpected situations. They might be utilized to develop contingency guidelines, especially for reducing the human error accident in NPPs. But the trial application in this study is currently limited since it is not easy to find accidents cases in detail enough to enumerate the proposed steps. Therefore, we will try to analyze as more cases as possible, and consider other environmental factors and human error conditions

A human error probability estimate methodology based on fuzzy inference and expert judgment on nuclear plants

International Nuclear Information System (INIS)

Nascimento, C.S. do; Mesquita, R.N. de

2009-01-01

Recent studies point human error as an important factor for many industrial and nuclear accidents: Three Mile Island (1979), Bhopal (1984), Chernobyl and Challenger (1986) are classical examples. Human contribution to these accidents may be better understood and analyzed by using Human Reliability Analysis (HRA), which has being taken as an essential part on Probabilistic Safety Analysis (PSA) of nuclear plants. Both HRA and PSA depend on Human Error Probability (HEP) for a quantitative analysis. These probabilities are extremely affected by the Performance Shaping Factors (PSF), which has a direct effect on human behavior and thus shape HEP according with specific environment conditions and personal individual characteristics which are responsible for these actions. This PSF dependence raises a great problem on data availability as turn these scarcely existent database too much generic or too much specific. Besides this, most of nuclear plants do not keep historical records of human error occurrences. Therefore, in order to overcome this occasional data shortage, a methodology based on Fuzzy Inference and expert judgment was employed in this paper in order to determine human error occurrence probabilities and to evaluate PSF's on performed actions by operators in a nuclear power plant (IEA-R1 nuclear reactor). Obtained HEP values were compared with reference tabled data used on current literature in order to show method coherence and valid approach. This comparison leads to a conclusion that this work results are able to be employed both on HRA and PSA enabling efficient prospection of plant safety conditions, operational procedures and local working conditions potential improvements (author)

Human Error Probability Assessment During Maintenance Activities of Marine Systems

Directory of Open Access Journals (Sweden)

Rabiul Islam

2018-03-01

Full Text Available Background: Maintenance operations on-board ships are highly demanding. Maintenance operations are intensive activities requiring high man–machine interactions in challenging and evolving conditions. The evolving conditions are weather conditions, workplace temperature, ship motion, noise and vibration, and workload and stress. For example, extreme weather condition affects seafarers' performance, increasing the chances of error, and, consequently, can cause injuries or fatalities to personnel. An effective human error probability model is required to better manage maintenance on-board ships. The developed model would assist in developing and maintaining effective risk management protocols. Thus, the objective of this study is to develop a human error probability model considering various internal and external factors affecting seafarers' performance. Methods: The human error probability model is developed using probability theory applied to Bayesian network. The model is tested using the data received through the developed questionnaire survey of >200 experienced seafarers with >5 years of experience. The model developed in this study is used to find out the reliability of human performance on particular maintenance activities. Results: The developed methodology is tested on the maintenance of marine engine's cooling water pump for engine department and anchor windlass for deck department. In the considered case studies, human error probabilities are estimated in various scenarios and the results are compared between the scenarios and the different seafarer categories. The results of the case studies for both departments are also compared. Conclusion: The developed model is effective in assessing human error probabilities. These probabilities would get dynamically updated as and when new information is available on changes in either internal (i.e., training, experience, and fatigue or external (i.e., environmental and operational conditions

Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms

Directory of Open Access Journals (Sweden)

M. Omidvari

2015-09-01

Full Text Available Introduction: Occupational accidents are of the main issues in industries. It is necessary to identify the main root causes of accidents for their control. Several models have been proposed for determining the accidents root causes. FTA is one of the most widely used models which could graphically establish the root causes of accidents. The non-linear function is one of the main challenges in FTA compliance and in order to obtain the exact number, the meta-heuristic algorithms can be used. Material and Method: The present research was done in power plant industries in construction phase. In this study, a pattern for the analysis of human error in work-related accidents was provided by combination of neural network algorithms and FTA analytical model. Finally, using this pattern, the potential rate of all causes was determined. Result: The results showed that training, age, and non-compliance with safety principals in the workplace were the most important factors influencing human error in the occupational accident. Conclusion: According to the obtained results, it can be concluded that human errors can be greatly reduced by training, right choice of workers with regard to the type of occupations, and provision of appropriate safety conditions in the work place.

Quantitative estimation of the human error probability during soft control operations

International Nuclear Information System (INIS)

Lee, Seung Jun; Kim, Jaewhan; Jung, Wondea

2013-01-01

Highlights: ► An HRA method to evaluate execution HEP for soft control operations was proposed. ► The soft control tasks were analyzed and design-related influencing factors were identified. ► An application to evaluate the effects of soft controls was performed. - Abstract: In this work, a method was proposed for quantifying human errors that can occur during operation executions using soft controls. Soft controls of advanced main control rooms have totally different features from conventional controls, and thus they may have different human error modes and occurrence probabilities. It is important to identify the human error modes and quantify the error probability for evaluating the reliability of the system and preventing errors. This work suggests an evaluation framework for quantifying the execution error probability using soft controls. In the application result, it was observed that the human error probabilities of soft controls showed both positive and negative results compared to the conventional controls according to the design quality of advanced main control rooms

Understanding Teamwork in Trauma Resuscitation through Analysis of Team Errors

Science.gov (United States)

Sarcevic, Aleksandra

2009-01-01

An analysis of human errors in complex work settings can lead to important insights into the workspace design. This type of analysis is particularly relevant to safety-critical, socio-technical systems that are highly dynamic, stressful and time-constrained, and where failures can result in catastrophic societal, economic or environmental…

Multidisciplinary framework for human reliability analysis with an application to errors of commission and dependencies

International Nuclear Information System (INIS)

Barriere, M.T.; Luckas, W.J.; Wreathall, J.; Cooper, S.E.; Bley, D.C.; Ramey-Smith, A.

1995-08-01

Since the early 1970s, human reliability analysis (HRA) has been considered to be an integral part of probabilistic risk assessments (PRAs). Nuclear power plant (NPP) events, from Three Mile Island through the mid-1980s, showed the importance of human performance to NPP risk. Recent events demonstrate that human performance continues to be a dominant source of risk. In light of these observations, the current limitations of existing HRA approaches become apparent when the role of humans is examined explicitly in the context of real NPP events. The development of new or improved HRA methodologies to more realistically represent human performance is recognized by the Nuclear Regulatory Commission (NRC) as a necessary means to increase the utility of PRAS. To accomplish this objective, an Improved HRA Project, sponsored by the NRC's Office of Nuclear Regulatory Research (RES), was initiated in late February, 1992, at Brookhaven National Laboratory (BNL) to develop an improved method for HRA that more realistically assesses the human contribution to plant risk and can be fully integrated with PRA. This report describes the research efforts including the development of a multidisciplinary HRA framework, the characterization and representation of errors of commission, and an approach for addressing human dependencies. The implications of the research and necessary requirements for further development also are discussed

Multidisciplinary framework for human reliability analysis with an application to errors of commission and dependencies

Energy Technology Data Exchange (ETDEWEB)

Barriere, M.T.; Luckas, W.J. [Brookhaven National Lab., Upton, NY (United States); Wreathall, J. [Wreathall (John) and Co., Dublin, OH (United States); Cooper, S.E. [Science Applications International Corp., Reston, VA (United States); Bley, D.C. [PLG, Inc., Newport Beach, CA (United States); Ramey-Smith, A. [Nuclear Regulatory Commission, Washington, DC (United States). Div. of Systems Technology

1995-08-01

Since the early 1970s, human reliability analysis (HRA) has been considered to be an integral part of probabilistic risk assessments (PRAs). Nuclear power plant (NPP) events, from Three Mile Island through the mid-1980s, showed the importance of human performance to NPP risk. Recent events demonstrate that human performance continues to be a dominant source of risk. In light of these observations, the current limitations of existing HRA approaches become apparent when the role of humans is examined explicitly in the context of real NPP events. The development of new or improved HRA methodologies to more realistically represent human performance is recognized by the Nuclear Regulatory Commission (NRC) as a necessary means to increase the utility of PRAS. To accomplish this objective, an Improved HRA Project, sponsored by the NRC`s Office of Nuclear Regulatory Research (RES), was initiated in late February, 1992, at Brookhaven National Laboratory (BNL) to develop an improved method for HRA that more realistically assesses the human contribution to plant risk and can be fully integrated with PRA. This report describes the research efforts including the development of a multidisciplinary HRA framework, the characterization and representation of errors of commission, and an approach for addressing human dependencies. The implications of the research and necessary requirements for further development also are discussed.

An investigation on unintended reactor trip events in terms of human error hazards of Korean nuclear power plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Lee, Yong Hee; Jang, Tong Il; Oh, Yeon Ju; Shin, Kwang Hyeon

2014-01-01

Highlights: • A methodology to identify human error hazards has been established. • The proposed methodology is a preventive approach to identify not only human error causes but also its hazards. • Using the HFACS framework we tried to find out not causations but all of the hazards and relationships among them. • We determined countermeasures against human errors through dealing with latent factors such as organizational influences. - Abstract: A new approach for finding the hazards of human errors, and not just their causes, in the nuclear industry is currently required. This is because finding causes of human errors is really impossible owing to the multiplicity of causes in each case. Thus, this study aims at identifying the relationships among human error hazards and determining the strategies for preventing human error events by means of a reanalysis of the reactor trip events in Korea NPPs. We investigated human errors to find latent factors such as decisions and conditions in all of the unintended reactor trip events during the last dozen years. In this study, we applied the HFACS (Human Factors Analysis and Classification System), which is a commonly utilized tool for investigating human contributions to aviation accidents under a widespread evaluation scheme. Using the HFACS framework, we tried to find out not the causations but all of the hazards and their relationships in terms of organizational factors. Through the trial, we proposed not only meaningful frequencies of each hazards also correlations of them. Also, considering the correlations of each hazards, we suggested useful strategies to prevent human error event. A method to investigate unintended nuclear reactor trips by human errors and the results will be discussed in more detail

Application of human reliability analysis methodology of second generation

International Nuclear Information System (INIS)

Ruiz S, T. de J.; Nelson E, P. F.

2009-10-01

The human reliability analysis (HRA) is a very important part of probabilistic safety analysis. The main contribution of HRA in nuclear power plants is the identification and characterization of the issues that are brought together for an error occurring in the human tasks that occur under normal operation conditions and those made after abnormal event. Additionally, the analysis of various accidents in history, it was found that the human component has been a contributing factor in the cause. Because of need to understand the forms and probability of human error in the 60 decade begins with the collection of generic data that result in the development of the first generation of HRA methodologies. Subsequently develop methods to include in their models additional performance shaping factors and the interaction between them. So by the 90 mid, comes what is considered the second generation methodologies. Among these is the methodology A Technique for Human Event Analysis (ATHEANA). The application of this method in a generic human failure event, it is interesting because it includes in its modeling commission error, the additional deviations quantification to nominal scenario considered in the accident sequence of probabilistic safety analysis and, for this event the dependency actions evaluation. That is, the generic human failure event was required first independent evaluation of the two related human failure events . So the gathering of the new human error probabilities involves the nominal scenario quantification and cases of significant deviations considered by the potential impact on analyzed human failure events. Like probabilistic safety analysis, with the analysis of the sequences were extracted factors more specific with the highest contribution in the human error probabilities. (Author)

Sensitivity of risk parameters to human errors for a PWR

International Nuclear Information System (INIS)

Samanta, P.; Hall, R.E.; Kerr, W.

1980-01-01

Sensitivities of the risk parameters, emergency safety system unavailabilities, accident sequence probabilities, release category probabilities and core melt probability were investigated for changes in the human error rates within the general methodological framework of the Reactor Safety Study for a Pressurized Water Reactor (PWR). Impact of individual human errors were assessed both in terms of their structural importance to core melt and reliability importance on core melt probability. The Human Error Sensitivity Assessment of a PWR (HESAP) computer code was written for the purpose of this study

Deadline pressure and human error: a study of human failures on a particle accelerator at Brookhaven National Laboratory

International Nuclear Information System (INIS)

Tiagha, E.A.

1982-01-01

The decline in industrial efficiency may be linked to decreased reliability of complex automatic systems. This decline threatens the viability of complex organizations in industrialized economies. Industrial engineering techniques that minimize system failure by increasing the reliability of systems hardware are well developed in comparison with those available to reduce human operator errors. The problem of system reliability and the associated costs of breakdown can be reduced if we understand how highly skilled technical personnel function in complex operations and systems. The purpose of this research is to investigate how human errors are affected by deadline pressures, technical communication and other socio-dynamic factors. Through the analysis of a technologically complex particle accelerator prototype at Brookhaven National Laboratory, two failure mechanisms: (1) physical defects in the production process and (2) human operator errors were identified. Two instruments were used to collect information on human failures: objective laboratory data and a human failure questionnaire. The results of human failures from the objective data were used to test for the deadline hypothesis and also to validate the human failure questionnaire. To explain why the human failures occurred, data were collected from a four-part, closed choice questionnaire administered to two groups of scientists, engineers, and technicians, working together against a deadline to produce an engineering prototype of a particle accelerator

ADVANCED MMIS TOWARD SUBSTANTIAL REDUCTION IN HUMAN ERRORS IN NPPS

Directory of Open Access Journals (Sweden)

POONG HYUN SEONG

2013-04-01

Full Text Available This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS. It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs. Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs.

Advanced MMIS Toward Substantial Reduction in Human Errors in NPPs

Energy Technology Data Exchange (ETDEWEB)

Seong, Poong Hyun; Kang, Hyun Gook [Korea Advanced Institute of Science and Technology, Daejeon (Korea, Republic of); Na, Man Gyun [Chosun Univ., Gwangju (Korea, Republic of); Kim, Jong Hyun [KEPCO International Nuclear Graduate School, Ulsan (Korea, Republic of); Heo, Gyunyoung [Kyung Hee Univ., Yongin (Korea, Republic of); Jung, Yoensub [Korea Hydro and Nuclear Power Co., Ltd., Daejeon (Korea, Republic of)

2013-04-15

This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS). It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs). Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs.

Advanced MMIS Toward Substantial Reduction in Human Errors in NPPs

International Nuclear Information System (INIS)

Seong, Poong Hyun; Kang, Hyun Gook; Na, Man Gyun; Kim, Jong Hyun; Heo, Gyunyoung; Jung, Yoensub

2013-01-01

This paper aims to give an overview of the methods to inherently prevent human errors and to effectively mitigate the consequences of such errors by securing defense-in-depth during plant management through the advanced man-machine interface system (MMIS). It is needless to stress the significance of human error reduction during an accident in nuclear power plants (NPPs). Unexpected shutdowns caused by human errors not only threaten nuclear safety but also make public acceptance of nuclear power extremely lower. We have to recognize there must be the possibility of human errors occurring since humans are not essentially perfect particularly under stressful conditions. However, we have the opportunity to improve such a situation through advanced information and communication technologies on the basis of lessons learned from our experiences. As important lessons, authors explained key issues associated with automation, man-machine interface, operator support systems, and procedures. Upon this investigation, we outlined the concept and technical factors to develop advanced automation, operation and maintenance support systems, and computer-based procedures using wired/wireless technology. It should be noted that the ultimate responsibility of nuclear safety obviously belongs to humans not to machines. Therefore, safety culture including education and training, which is a kind of organizational factor, should be emphasized as well. In regard to safety culture for human error reduction, several issues that we are facing these days were described. We expect the ideas of the advanced MMIS proposed in this paper to lead in the future direction of related researches and finally supplement the safety of NPPs

The Relationship between Human Operators' Psycho-physiological Condition and Human Errors in Nuclear Power Plants

International Nuclear Information System (INIS)

Kim, Arryum; Jang, Inseok; Kang, Hyungook; Seong, Poonghyun

2013-01-01

The safe operation of nuclear power plants (NPPs) is substantially dependent on the performance of the human operators who operate the systems. In this environment, human errors caused by inappropriate performance of operator have been considered to be critical since it may lead serious problems in the safety-critical plants. In order to provide meaningful insights to prevent human errors and enhance the human performance, operators' physiological conditions such as stress and workload have been investigated. Physiological measurements were considered as reliable tools to assess the stress and workload. T. Q. Tran et al. and J. B. Brooking et al pointed out that operators' workload can be assessed using eye tracking, galvanic skin response, electroencephalograms (EEGs), heart rate, respiration and other measurements. The purpose of this study is to investigate the effect of the human operators' tense level and knowledge level to the number of human errors. For this study, the experiments were conducted in the mimic of the main control rooms (MCR) in NPP. It utilized the compact nuclear simulator (CNS) which is modeled based on the three loop Pressurized Water Reactor, 993MWe, Kori unit 3 and 4 in Korea and the subjects were asked to follow the tasks described in the emergency operating procedures (EOP). During the simulation, three kinds of physiological measurement were utilized; Electrocardiogram (ECG), EEG and nose temperature. Also, subjects were divided into three groups based on their knowledge of the plant operation. The result shows that subjects who are tense make fewer errors. In addition, subjects who are in higher knowledge level tend to be tense and make fewer errors. For the ECG data, subjects who make fewer human errors tend to be located in higher tense level area of high SNS activity and low PSNS activity. The results of EEG data are also similar to ECG result. Beta power ratio of subjects who make fewer errors was higher. Since beta power ratio is

Investigating the causes of human error-induced incidents in the maintenance operations of petrochemical industry by using HFACS

Directory of Open Access Journals (Sweden)

Mohammadreza Azhdari

2017-03-01

Full Text Available Background & Objectives: Maintenance is an important tool for the petrochemical industries to prevent of accidents and increase operational and process safety success. The purpose of this study was to identify the possible causes of incidents caused by human error in the petrochemical maintenance activities by using Human Factors Analysis and Classification System (HFACS. Methods: This study is a cross-sectional analysis that was conducted in Zagros Petrochemical Company, Asaluyeh-Iran. A checklist of human error-induced incidents was developed based on four HFACS main levels and nineteen sub-groups. Hierarchical task analysis (HTA technique was used to identify maintenance activities and tasks. The main causes of possible incidents were identified by checklist and recorded. Corrective and preventive actions were defined depending on priority.   Results: The content analysis of worksheets of 444 activities showed 37.6% of the causes at the level of unsafe actions, 27.5% at the level of unsafe supervision, 20.9% at the level of preconditions for unsafe acts and 14% of the causes at the level of organizational effects. The HFACS sub-groups showed errors (24.36% inadequate supervision (14.89% and violations (13.26% with the most frequency. Conclusion: In order to prevent and reduce the occurrence of the identified errors, reducing the rate of the detected errors is crucial. Findings of this study showed that appropriate controlling measures such as periodical training of work procedures and supervision improvement decrease the human error-induced incidents in petrochemical industry maintenance.

Quantification of human errors in level-1 PSA studies in NUPEC/JINS

International Nuclear Information System (INIS)

Hirano, M.; Hirose, M.; Sugawara, M.; Hashiba, T.

1991-01-01

THERP (Technique for Human Error Rate Prediction) method is mainly adopted to evaluate the pre-accident and post-accident human error rates. Performance shaping factors are derived by taking Japanese operational practice into account. Several examples of human error rates with calculational procedures are presented. The important human interventions of typical Japanese NPPs are also presented. (orig./HP)

Human error data collection analysis program undertaken since 1982 by Electricite de France with INPO

International Nuclear Information System (INIS)

Ghertman, F.; Dietz, P.

1985-01-01

The preoccupation for reducing in frequency and importance events which harm at various degrees the availability, the safety and the security of nuclear power plants lead Electricite de France, in cooperation with INPO (Institute of Nuclear Power Operations) to launch a Human Error Collection and Analysis Program. On account with the difficulties met to develop such a program, it has been decided to begin with a pilot data collection limited to a six months period (October 1982 to April 1983) and three nuclear power plants (three US units and two French units). This pilot data collection followed four steps: (1) elaboration of the collection methodology; (2) sensitization and related training of the power plant personnel; (3) data collection in the power plant; and (4) analysis of the data and results. Each of the steps are discussed in the paper

The dependence level analysis between the human actions in NPP Operation

International Nuclear Information System (INIS)

Farcasiu, M.; Nitoi, M.; Apostol, M.; Florescu, G.; Prisecaru, Ilie

2009-01-01

The Human Reliability Analysis (HRA) is an important method in Probabilistic Safety Assessment (PSA) studies and offers desirability for concrete improvement of the man - machine - organization interfaces, reliability and safety. An important step in HRA is the dependence level analysis between the human actions performed by the same person or between the actions performed by different persons, step in quantitative analysis of the human errors probabilities. The purpose of this paper is to develop a model to analyze the dependence level between human actions for Nuclear Power Plant (NPP) operation. The model estimates the conditional human error probabilities (CHEP) and joint human error probabilities (JHEP). The achieved sensitivity analyses determine human performance sensibility to systematic variations for dependence level between human actions. The human error probabilities estimated in this paper are adequate values for integration both in HRA and in PSA realized for NPP. This type of analysis helps in finding and analyzing the ways of reducing the likelihood of human errors, so that the impact of human factor to systems availability, reliability and safety can be realistically estimated. In order to demonstrate the usability of this model an analysis is performed upon the dependences between the necessary human actions in mitigating the consequences of LOCA events, particularly for the case of Cernavoda NPP. (authors)

The Concept of Human Error and the Design of Reliable Human-Machine Systems

DEFF Research Database (Denmark)

Rasmussen, Jens

1995-01-01

The concept of human error is unreliable as a basis for design of reliable human-machine systems. Humans are basically highly adaptive and 'errors' are closely related to the process of adaptation and learning. Therefore, reliability of system operation depends on an interface that is not designed...... so as to support a pre-conceived operating procedure, but, instead, makes visible the deep, functional structure of the system together with the boundaries of acceptable operation in away that allows operators to 'touch' the boundaries and to learn to cope with the effects of errors in a reversible...... way. The concepts behind such 'ecological' interfaces are discussed, an it is argued that a 'typology' of visualization concepts is a pressing research need....

Team errors: definition and taxonomy

International Nuclear Information System (INIS)

Sasou, Kunihide; Reason, James

1999-01-01

In error analysis or error management, the focus is usually upon individuals who have made errors. In large complex systems, however, most people work in teams or groups. Considering this working environment, insufficient emphasis has been given to 'team errors'. This paper discusses the definition of team errors and its taxonomy. These notions are also applied to events that have occurred in the nuclear power industry, aviation industry and shipping industry. The paper also discusses the relations between team errors and Performance Shaping Factors (PSFs). As a result, the proposed definition and taxonomy are found to be useful in categorizing team errors. The analysis also reveals that deficiencies in communication, resource/task management, excessive authority gradient, excessive professional courtesy will cause team errors. Handling human errors as team errors provides an opportunity to reduce human errors

The development of human behavior analysis techniques

International Nuclear Information System (INIS)

Lee, Jung Woon; Lee, Yong Hee; Park, Geun Ok; Cheon, Se Woo; Suh, Sang Moon; Oh, In Suk; Lee, Hyun Chul; Park, Jae Chang.

1997-07-01

In this project, which is to study on man-machine interaction in Korean nuclear power plants, we developed SACOM (Simulation Analyzer with a Cognitive Operator Model), a tool for the assessment of task performance in the control rooms using software simulation, and also develop human error analysis and application techniques. SACOM was developed to assess operator's physical workload, workload in information navigation at VDU workstations, and cognitive workload in procedural tasks. We developed trip analysis system including a procedure based on man-machine interaction analysis system including a procedure based on man-machine interaction analysis and a classification system. We analyzed a total of 277 trips occurred from 1978 to 1994 to produce trip summary information, and for 79 cases induced by human errors time-lined man-machine interactions. The INSTEC, a database system of our analysis results, was developed. The MARSTEC, a multimedia authoring and representation system for trip information, was also developed, and techniques for human error detection in human factors experiments were established. (author). 121 refs., 38 tabs., 52 figs

The development of human behavior analysis techniques

Energy Technology Data Exchange (ETDEWEB)

Lee, Jung Woon; Lee, Yong Hee; Park, Geun Ok; Cheon, Se Woo; Suh, Sang Moon; Oh, In Suk; Lee, Hyun Chul; Park, Jae Chang

1997-07-01

In this project, which is to study on man-machine interaction in Korean nuclear power plants, we developed SACOM (Simulation Analyzer with a Cognitive Operator Model), a tool for the assessment of task performance in the control rooms using software simulation, and also develop human error analysis and application techniques. SACOM was developed to assess operator`s physical workload, workload in information navigation at VDU workstations, and cognitive workload in procedural tasks. We developed trip analysis system including a procedure based on man-machine interaction analysis system including a procedure based on man-machine interaction analysis and a classification system. We analyzed a total of 277 trips occurred from 1978 to 1994 to produce trip summary information, and for 79 cases induced by human errors time-lined man-machine interactions. The INSTEC, a database system of our analysis results, was developed. The MARSTEC, a multimedia authoring and representation system for trip information, was also developed, and techniques for human error detection in human factors experiments were established. (author). 121 refs., 38 tabs., 52 figs.

Error detection in spoken human-machine interaction

NARCIS (Netherlands)

Krahmer, E.J.; Swerts, M.G.J.; Theune, M.; Weegels, M.F.

2001-01-01

Given the state of the art of current language and speech technology, errors are unavoidable in present-day spoken dialogue systems. Therefore, one of the main concerns in dialogue design is how to decide whether or not the system has understood the user correctly. In human-human communication,

Error detection in spoken human-machine interaction

NARCIS (Netherlands)

Krahmer, E.; Swerts, M.; Theune, Mariet; Weegels, M.

Given the state of the art of current language and speech technology, errors are unavoidable in present-day spoken dialogue systems. Therefore, one of the main concerns in dialogue design is how to decide whether or not the system has understood the user correctly. In human-human communication,

Analysis of Medication Error Reports

Energy Technology Data Exchange (ETDEWEB)

Whitney, Paul D.; Young, Jonathan; Santell, John; Hicks, Rodney; Posse, Christian; Fecht, Barbara A.

2004-11-15

In medicine, as in many areas of research, technological innovation and the shift from paper based information to electronic records has created a climate of ever increasing availability of raw data. There has been, however, a corresponding lag in our abilities to analyze this overwhelming mass of data, and classic forms of statistical analysis may not allow researchers to interact with data in the most productive way. This is true in the emerging area of patient safety improvement. Traditionally, a majority of the analysis of error and incident reports has been carried out based on an approach of data comparison, and starts with a specific question which needs to be answered. Newer data analysis tools have been developed which allow the researcher to not only ask specific questions but also to “mine” data: approach an area of interest without preconceived questions, and explore the information dynamically, allowing questions to be formulated based on patterns brought up by the data itself. Since 1991, United States Pharmacopeia (USP) has been collecting data on medication errors through voluntary reporting programs. USP’s MEDMARXsm reporting program is the largest national medication error database and currently contains well over 600,000 records. Traditionally, USP has conducted an annual quantitative analysis of data derived from “pick-lists” (i.e., items selected from a list of items) without an in-depth analysis of free-text fields. In this paper, the application of text analysis and data analysis tools used by Battelle to analyze the medication error reports already analyzed in the traditional way by USP is described. New insights and findings were revealed including the value of language normalization and the distribution of error incidents by day of the week. The motivation for this effort is to gain additional insight into the nature of medication errors to support improvements in medication safety.

Integrating human factors into process hazard analysis

International Nuclear Information System (INIS)

Kariuki, S.G.; Loewe, K.

2007-01-01

A comprehensive process hazard analysis (PHA) needs to address human factors. This paper describes an approach that systematically identifies human error in process design and the human factors that influence its production and propagation. It is deductive in nature and therefore considers human error as a top event. The combinations of different factors that may lead to this top event are analysed. It is qualitative in nature and is used in combination with other PHA methods. The method has an advantage because it does not look at the operator error as the sole contributor to the human failure within a system but a combination of all underlying factors

Human errors evaluation for muster in emergency situations applying human error probability index (HEPI, in the oil company warehouse in Hamadan City

Directory of Open Access Journals (Sweden)

2012-12-01

Full Text Available Introduction: Emergency situation is one of the influencing factors on human error. The aim of this research was purpose to evaluate human error in emergency situation of fire and explosion at the oil company warehouse in Hamadan city applying human error probability index (HEPI. . Material and Method: First, the scenario of emergency situation of those situation of fire and explosion at the oil company warehouse was designed and then maneuver against, was performed. The scaled questionnaire of muster for the maneuver was completed in the next stage. Collected data were analyzed to calculate the probability success for the 18 actions required in an emergency situation from starting point of the muster until the latest action to temporary sheltersafe. .Result: The result showed that the highest probability of error occurrence was related to make safe workplace (evaluation phase with 32.4 % and lowest probability of occurrence error in detection alarm (awareness phase with 1.8 %, probability. The highest severity of error was in the evaluation phase and the lowest severity of error was in the awareness and recovery phase. Maximum risk level was related to the evaluating exit routes and selecting one route and choosy another exit route and minimum risk level was related to the four evaluation phases. . Conclusion: To reduce the risk of reaction in the exit phases of an emergency situation, the following actions are recommended, based on the finding in this study: A periodic evaluation of the exit phase and modifying them if necessary, conducting more maneuvers and analyzing this results along with a sufficient feedback to the employees.

The Relationship between Human Operators' Psycho-physiological Condition and Human Errors in Nuclear Power Plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Arryum; Jang, Inseok; Kang, Hyungook; Seong, Poonghyun [Korea Advanced Institute of Science and Technology, Daejeon (Korea, Republic of)

2013-05-15

The safe operation of nuclear power plants (NPPs) is substantially dependent on the performance of the human operators who operate the systems. In this environment, human errors caused by inappropriate performance of operator have been considered to be critical since it may lead serious problems in the safety-critical plants. In order to provide meaningful insights to prevent human errors and enhance the human performance, operators' physiological conditions such as stress and workload have been investigated. Physiological measurements were considered as reliable tools to assess the stress and workload. T. Q. Tran et al. and J. B. Brooking et al pointed out that operators' workload can be assessed using eye tracking, galvanic skin response, electroencephalograms (EEGs), heart rate, respiration and other measurements. The purpose of this study is to investigate the effect of the human operators' tense level and knowledge level to the number of human errors. For this study, the experiments were conducted in the mimic of the main control rooms (MCR) in NPP. It utilized the compact nuclear simulator (CNS) which is modeled based on the three loop Pressurized Water Reactor, 993MWe, Kori unit 3 and 4 in Korea and the subjects were asked to follow the tasks described in the emergency operating procedures (EOP). During the simulation, three kinds of physiological measurement were utilized; Electrocardiogram (ECG), EEG and nose temperature. Also, subjects were divided into three groups based on their knowledge of the plant operation. The result shows that subjects who are tense make fewer errors. In addition, subjects who are in higher knowledge level tend to be tense and make fewer errors. For the ECG data, subjects who make fewer human errors tend to be located in higher tense level area of high SNS activity and low PSNS activity. The results of EEG data are also similar to ECG result. Beta power ratio of subjects who make fewer errors was higher. Since beta

Disasters of endoscopic surgery and how to avoid them: error analysis.

Science.gov (United States)

Troidl, H

1999-08-01

For every innovation there are two sides to consider. For endoscopic surgery the positive side is more comfort for the patient, and the negative side is new complications, even disasters, such as injuries to organs (e.g., the bowel), vessels, and the common bile duct. These disasters are rare and seldom reported in the scientific world, as at conferences, at symposiums, and in publications. Today there are many methods for testing an innovation (controlled clinical trials, consensus conferences, audits, and confidential inquiries). Reporting "complications," however, does not help to avoid them. We need real methods for avoiding negative failures. The failure analysis is the method of choice in industry. If an airplane crashes, error analysis starts immediately. Humans make errors, and making errors means punishment. Failure analysis means rigorously and objectively investigating a clinical situation to find clinical relevant information for avoiding these negative events in the future. Error analysis has four important steps: (1) What was the clinical situation? (2) What has happened? (3) Most important: Why did it happen? (4) How do we avoid the negative event or disaster in the future. Error analysis has decisive advantages. It is easy to perform; it supplies clinically relevant information to help avoid it; and there is no need for money. It can be done everywhere; and the information is available in a short time. The other side of the coin is that error analysis is of course retrospective, it may not be objective, and most important it will probably have legal consequences. To be more effective in medicine and surgery we must handle our errors using a different approach. According to Sir Karl Popper: "The consituation is that we have to learn from our errors. To cover up failure is therefore the biggest intellectual sin.

Analysis for Human-related Events during the Overhaul

Energy Technology Data Exchange (ETDEWEB)

Kim, Ji Tae; Kim, Min Chull; Choi, Dong Won; Lee, Durk Hun [Korea Institute of Nuclear Safety, Daejeon (Korea, Republic of)

2011-10-15

The event frequency due to human error is decreasing among 20 operating Nuclear Power Plants (NPPs) excluding the NPP (Shin-Kori unit-1) in the commissioning stage since 2008. However, the events due to human error during an overhaul (O/H) occur annually (see Table I). An analysis for human-related events during the O/H was performed. Similar problems were identified for each event from the analysis and also, organizational and safety cultural factors were also identified

A system engineer's Perspective on Human Errors For a more Effective Management of Human Factors in Nuclear Power Plants

International Nuclear Information System (INIS)

Lee, Yong-Hee; Jang, Tong-Il; Lee, Soo-Kil

2007-01-01

The management of human factors in nuclear power plants (NPPs) has become one of the burden factors during their operating period after the design and construction period. Almost every study on the major accidents emphasizes the prominent importance of the human errors. Regardless of the regulatory requirements such as Periodic Safety Review, the management of human factors would be a main issue to reduce the human errors and to enhance the performance of plants. However, it is not easy to find out a more effective perspective on human errors to establish the engineering implementation plan for preventing them. This paper describes a system engineer's perspectives on human errors and discusses its application to the recent study on the human error events in Korean NPPs

A Sensitivity Study of Human Errors in Optimizing Surveillance Test Interval (STI) and Allowed Outage Time (AOT) of Standby Safety System

International Nuclear Information System (INIS)

Chung, Dae Wook; Shin, Won Ky; You, Young Woo; Yang, Hui Chang

1998-01-01

In most cases, the surveillance test intervals (STIs), allowed outage times (AOTS) and testing strategies of safety components in nuclear power plant are prescribed in plant technical specifications. And, in general, it is required that standby safety system shall be redundant (i.e., composed of multiple components) and these components are tested by either staggered test strategy or sequential test strategy. In this study, a linear model is presented to incorporate the effects of human errors associated with test into the evaluation of unavailability. The average unavailabilities of 1/4, 2/4 redundant systems are computed considering human error and testing strategy. The adverse effects of test on system unavailability, such as component wear and test-induced transient have been modelled. The final outcome of this study would be the optimized human error domain from 3-D human error sensitivity analysis by selecting finely classified segment. The results of sensitivity analysis show that the STI and AOT can be optimized provided human error probability is maintained within allowable range. (authors)

Development of Human Performance Analysis and Advanced HRA Methodology

Energy Technology Data Exchange (ETDEWEB)

Jung, Won Dea; Park, Jin Kyun; Kim, Jae Whan; Kim, Seong Whan; Kim, Man Cheol; Ha, Je Joo

2007-06-15

The purpose of this project is to build a systematic framework that can evaluate the effect of human factors related problems on the safety of nuclear power plants (NPPs) as well as develop a technology that can be used to enhance human performance. The research goal of this project is twofold: (1) the development of a human performance database and a framework to enhance human performance, and (2) the analysis of human error with constructing technical basis for human reliability analysis. There are three kinds of main results of this study. The first result is the development of a human performance database, called OPERA-I/II (Operator Performance and Reliability Analysis, Part I and Part II). In addition, a standard communication protocol was developed based on OPERA to reduce human error caused from communication error in the phase of event diagnosis. Task complexity (TACOM) measure and the methodology of optimizing diagnosis procedures were also finalized during this research phase. The second main result is the development of a software, K-HRA, which is to support the standard HRA method. Finally, an advanced HRA method named as AGAPE-ET was developed by combining methods MDTA (misdiagnosis tree analysis technique) and K-HRA, which can be used to analyze EOC (errors of commission) and EOO (errors of ommission). These research results, such as OPERA-I/II, TACOM, a standard communication protocol, K-HRA and AGAPE-ET methods will be used to improve the quality of HRA and to enhance human performance in nuclear power plants.

Development of Human Performance Analysis and Advanced HRA Methodology

International Nuclear Information System (INIS)

Jung, Won Dea; Park, Jin Kyun; Kim, Jae Whan; Kim, Seong Whan; Kim, Man Cheol; Ha, Je Joo

2007-06-01

The purpose of this project is to build a systematic framework that can evaluate the effect of human factors related problems on the safety of nuclear power plants (NPPs) as well as develop a technology that can be used to enhance human performance. The research goal of this project is twofold: (1) the development of a human performance database and a framework to enhance human performance, and (2) the analysis of human error with constructing technical basis for human reliability analysis. There are three kinds of main results of this study. The first result is the development of a human performance database, called OPERA-I/II (Operator Performance and Reliability Analysis, Part I and Part II). In addition, a standard communication protocol was developed based on OPERA to reduce human error caused from communication error in the phase of event diagnosis. Task complexity (TACOM) measure and the methodology of optimizing diagnosis procedures were also finalized during this research phase. The second main result is the development of a software, K-HRA, which is to support the standard HRA method. Finally, an advanced HRA method named as AGAPE-ET was developed by combining methods MDTA (misdiagnosis tree analysis technique) and K-HRA, which can be used to analyze EOC (errors of commission) and EOO (errors of ommission). These research results, such as OPERA-I/II, TACOM, a standard communication protocol, K-HRA and AGAPE-ET methods will be used to improve the quality of HRA and to enhance human performance in nuclear power plants

Hierarchical learning induces two simultaneous, but separable, prediction errors in human basal ganglia.

Science.gov (United States)

Diuk, Carlos; Tsai, Karin; Wallis, Jonathan; Botvinick, Matthew; Niv, Yael

2013-03-27

Studies suggest that dopaminergic neurons report a unitary, global reward prediction error signal. However, learning in complex real-life tasks, in particular tasks that show hierarchical structure, requires multiple prediction errors that may coincide in time. We used functional neuroimaging to measure prediction error signals in humans performing such a hierarchical task involving simultaneous, uncorrelated prediction errors. Analysis of signals in a priori anatomical regions of interest in the ventral striatum and the ventral tegmental area indeed evidenced two simultaneous, but separable, prediction error signals corresponding to the two levels of hierarchy in the task. This result suggests that suitably designed tasks may reveal a more intricate pattern of firing in dopaminergic neurons. Moreover, the need for downstream separation of these signals implies possible limitations on the number of different task levels that we can learn about simultaneously.

Human performance analysis in the frame of probabilistic safety assessment of research reactors

International Nuclear Information System (INIS)

Farcasiu, Mita; Nitoi, Mirela; Apostol, Minodora; Turcu, I.; Florescu, Gh.

2005-01-01

Full text: The analysis of operating experience has identified the importance of human performance in reliability and safety of research reactors. In Probabilistic Safety Assessment (PSA) of nuclear facilities, human performance analysis (HPA) is used in order to estimate human error contribution to the failure of system components or functions. HPA is a qualitative and quantitative analysis of human actions identified for error-likely situations or accident-prone situations. Qualitative analysis is used to identify all man-machine interfaces that can lead to an accident, types of human interactions which may mitigate or exacerbate the accident, types of human errors and performance shaping factors. Quantitative analysis is used to develop estimates of human error probability as effects of human performance in reliability and safety. The goal of this paper is to accomplish a HPA in the PSA frame for research reactors. Human error probabilities estimated as results of human actions analysis could be included in system event tree and/or system fault tree. The achieved sensitivity analyses determine human performance sensibility at systematically variations both for dependencies level between human actions and for operator stress level. The necessary information was obtained from operating experience of research reactor TRIGA from INR Pitesti. The required data were obtained from generic data bases. (authors)

A strategy for minimizing common mode human error in executing critical functions and tasks

International Nuclear Information System (INIS)

Beltracchi, L.; Lindsay, R.W.

1992-01-01

Human error in execution of critical functions and tasks can be costly. The Three Mile Island and the Chernobyl Accidents are examples of results from human error in the nuclear industry. There are similar errors that could no doubt be cited from other industries. This paper discusses a strategy to minimize common mode human error in the execution of critical functions and tasks. The strategy consists of the use of human redundancy, and also diversity in human cognitive behavior: skill-, rule-, and knowledge-based behavior. The authors contend that the use of diversity in human cognitive behavior is possible, and it minimizes common mode error

Advancing Usability Evaluation through Human Reliability Analysis

International Nuclear Information System (INIS)

Ronald L. Boring; David I. Gertman

2005-01-01

This paper introduces a novel augmentation to the current heuristic usability evaluation methodology. The SPAR-H human reliability analysis method was developed for categorizing human performance in nuclear power plants. Despite the specialized use of SPAR-H for safety critical scenarios, the method also holds promise for use in commercial off-the-shelf software usability evaluations. The SPAR-H method shares task analysis underpinnings with human-computer interaction, and it can be easily adapted to incorporate usability heuristics as performance shaping factors. By assigning probabilistic modifiers to heuristics, it is possible to arrive at the usability error probability (UEP). This UEP is not a literal probability of error but nonetheless provides a quantitative basis to heuristic evaluation. When combined with a consequence matrix for usability errors, this method affords ready prioritization of usability issues

Catching errors with patient-specific pretreatment machine log file analysis.

Science.gov (United States)

Rangaraj, Dharanipathy; Zhu, Mingyao; Yang, Deshan; Palaniswaamy, Geethpriya; Yaddanapudi, Sridhar; Wooten, Omar H; Brame, Scott; Mutic, Sasa

2013-01-01

A robust, efficient, and reliable quality assurance (QA) process is highly desired for modern external beam radiation therapy treatments. Here, we report the results of a semiautomatic, pretreatment, patient-specific QA process based on dynamic machine log file analysis clinically implemented for intensity modulated radiation therapy (IMRT) treatments delivered by high energy linear accelerators (Varian 2100/2300 EX, Trilogy, iX-D, Varian Medical Systems Inc, Palo Alto, CA). The multileaf collimator machine (MLC) log files are called Dynalog by Varian. Using an in-house developed computer program called "Dynalog QA," we automatically compare the beam delivery parameters in the log files that are generated during pretreatment point dose verification measurements, with the treatment plan to determine any discrepancies in IMRT deliveries. Fluence maps are constructed and compared between the delivered and planned beams. Since clinical introduction in June 2009, 912 machine log file analyses QA were performed by the end of 2010. Among these, 14 errors causing dosimetric deviation were detected and required further investigation and intervention. These errors were the result of human operating mistakes, flawed treatment planning, and data modification during plan file transfer. Minor errors were also reported in 174 other log file analyses, some of which stemmed from false positives and unreliable results; the origins of these are discussed herein. It has been demonstrated that the machine log file analysis is a robust, efficient, and reliable QA process capable of detecting errors originating from human mistakes, flawed planning, and data transfer problems. The possibility of detecting these errors is low using point and planar dosimetric measurements. Copyright © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.

Assessment of modern methods of human factor reliability analysis in PSA studies

International Nuclear Information System (INIS)

Holy, J.

2001-12-01

The report is structured as follows: Classical terms and objects (Probabilistic safety assessment as a framework for human reliability assessment; Human failure within the PSA model; Basic types of operator failure modelled in a PSA study and analyzed by HRA methods; Qualitative analysis of human reliability; Quantitative analysis of human reliability used; Process of analysis of nuclear reactor operator reliability in a PSA study); New terms and objects (Analysis of dependences; Errors of omission; Errors of commission; Error forcing context); and Overview and brief assessment of human reliability analysis (Basic characteristics of the methods; Assets and drawbacks of the use of each of HRA method; History and prospects of the use of the methods). (P.A.)

Development of an Experimental Measurement System for Human Error Characteristics and a Pilot Test

International Nuclear Information System (INIS)

Jang, Tong-Il; Lee, Hyun-Chul; Moon, Kwangsu

2017-01-01

Some items out of individual and team characteristics were partially selected, and a pilot test was performed to measure and evaluate them using the experimental measurement system of human error characteristics. It is one of the processes to produce input data to the Eco-DBMS. And also, through the pilot test, it was tried to take methods to measure and acquire the physiological data, and to develop data format and quantification methods for the database. In this study, a pilot test to measure the stress and the tension level, and team cognitive characteristics out of human error characteristics was performed using the human error characteristics measurement and experimental evaluation system. In an experiment measuring the stress level, physiological characteristics using EEG was measured in a simulated unexpected situation. As shown in results, although this experiment was pilot, it was validated that relevant results for evaluating human error coping effects of workers’ FFD management guidelines and unexpected situation against guidelines can be obtained. In following researches, additional experiments including other human error characteristics will be conducted. Furthermore, the human error characteristics measurement and experimental evaluation system will be utilized to validate various human error coping solutions such as human factors criteria, design, and guidelines as well as supplement the human error characteristics database.

A Comparative Study on Error Analysis

DEFF Research Database (Denmark)

Wu, Xiaoli; Zhang, Chun

2015-01-01

Title: A Comparative Study on Error Analysis Subtitle: - Belgian (L1) and Danish (L1) learners’ use of Chinese (L2) comparative sentences in written production Xiaoli Wu, Chun Zhang Abstract: Making errors is an inevitable and necessary part of learning. The collection, classification and analysis...... the occurrence of errors either in linguistic or pedagogical terms. The purpose of the current study is to demonstrate the theoretical and practical relevance of error analysis approach in CFL by investigating two cases - (1) Belgian (L1) learners’ use of Chinese (L2) comparative sentences in written production...... of errors in the written and spoken production of L2 learners has a long tradition in L2 pedagogy. Yet, in teaching and learning Chinese as a foreign language (CFL), only handful studies have been made either to define the ‘error’ in a pedagogically insightful way or to empirically investigate...

A critique of recent models for human error rate assessment

International Nuclear Information System (INIS)

Apostolakis, G.E.

1988-01-01

This paper critically reviews two groups of models for assessing human error rates under accident conditions. The first group, which includes the US Nuclear Regulatory Commission (NRC) handbook model and the human cognitive reliability (HCR) model, considers as fundamental the time that is available to the operators to act. The second group, which is represented by the success likelihood index methodology multiattribute utility decomposition (SLIM-MAUD) model, relies on ratings of the human actions with respect to certain qualitative factors and the subsequent derivation of error rates. These models are evaluated with respect to two criteria: the treatment of uncertainties and the internal coherence of the models. In other words, this evaluation focuses primarily on normative aspects of these models. The principal findings are as follows: (1) Both of the time-related models provide human error rates as a function of the available time for action and the prevailing conditions. However, the HCR model ignores the important issue of state-of-knowledge uncertainties, dealing exclusively with stochastic uncertainty, whereas the model presented in the NRC handbook handles both types of uncertainty. (2) SLIM-MAUD provides a highly structured approach for the derivation of human error rates under given conditions. However, the treatment of the weights and ratings in this model is internally inconsistent. (author)

Some aspects of statistical modeling of human-error probability

International Nuclear Information System (INIS)

Prairie, R.R.

1982-01-01

Human reliability analyses (HRA) are often performed as part of risk assessment and reliability projects. Recent events in nuclear power have shown the potential importance of the human element. There are several on-going efforts in the US and elsewhere with the purpose of modeling human error such that the human contribution can be incorporated into an overall risk assessment associated with one or more aspects of nuclear power. An effort that is described here uses the HRA (event tree) to quantify and model the human contribution to risk. As an example, risk analyses are being prepared on several nuclear power plants as part of the Interim Reliability Assessment Program (IREP). In this process the risk analyst selects the elements of his fault tree that could be contributed to by human error. He then solicits the HF analyst to do a HRA on this element

Sleep quality, posttraumatic stress, depression, and human errors in train drivers: a population-based nationwide study in South Korea.

Science.gov (United States)

Jeon, Hong Jin; Kim, Ji-Hae; Kim, Bin-Na; Park, Seung Jin; Fava, Maurizio; Mischoulon, David; Kang, Eun-Ho; Roh, Sungwon; Lee, Dongsoo

2014-12-01

Human error is defined as an unintended error that is attributable to humans rather than machines, and that is important to avoid to prevent accidents. We aimed to investigate the association between sleep quality and human errors among train drivers. Cross-sectional. Population-based. A sample of 5,480 subjects who were actively working as train drivers were recruited in South Korea. The participants were 4,634 drivers who completed all questionnaires (response rate 84.6%). None. The Pittsburgh Sleep Quality Index (PSQI), the Center for Epidemiologic Studies Depression Scale (CES-D), the Impact of Event Scale-Revised (IES-R), the State-Trait Anxiety Inventory (STAI), and the Korean Occupational Stress Scale (KOSS). Of 4,634 train drivers, 349 (7.5%) showed more than one human error per 5 y. Human errors were associated with poor sleep quality, higher PSQI total scores, short sleep duration at night, and longer sleep latency. Among train drivers with poor sleep quality, those who experienced severe posttraumatic stress showed a significantly higher number of human errors than those without. Multiple logistic regression analysis showed that human errors were significantly associated with poor sleep quality and posttraumatic stress, whereas there were no significant associations with depression, trait and state anxiety, and work stress after adjusting for age, sex, education years, marital status, and career duration. Poor sleep quality was found to be associated with more human errors in train drivers, especially in those who experienced severe posttraumatic stress. © 2014 Associated Professional Sleep Societies, LLC.

Development of safety analysis and constraint detection techniques for process interaction errors

Energy Technology Data Exchange (ETDEWEB)

Fan, Chin-Feng, E-mail: csfanc@saturn.yzu.edu.tw [Computer Science and Engineering Dept., Yuan-Ze University, Taiwan (China); Tsai, Shang-Lin; Tseng, Wan-Hui [Computer Science and Engineering Dept., Yuan-Ze University, Taiwan (China)

2011-02-15

Among the new failure modes introduced by computer into safety systems, the process interaction error is the most unpredictable and complicated failure mode, which may cause disastrous consequences. This paper presents safety analysis and constraint detection techniques for process interaction errors among hardware, software, and human processes. Among interaction errors, the most dreadful ones are those that involve run-time misinterpretation from a logic process. We call them the 'semantic interaction errors'. Such abnormal interaction is not adequately emphasized in current research. In our static analysis, we provide a fault tree template focusing on semantic interaction errors by checking conflicting pre-conditions and post-conditions among interacting processes. Thus, far-fetched, but highly risky, interaction scenarios involve interpretation errors can be identified. For run-time monitoring, a range of constraint types is proposed for checking abnormal signs at run time. We extend current constraints to a broader relational level and a global level, considering process/device dependencies and physical conservation rules in order to detect process interaction errors. The proposed techniques can reduce abnormal interactions; they can also be used to assist in safety-case construction.

Development of safety analysis and constraint detection techniques for process interaction errors

International Nuclear Information System (INIS)

Fan, Chin-Feng; Tsai, Shang-Lin; Tseng, Wan-Hui

2011-01-01

Among the new failure modes introduced by computer into safety systems, the process interaction error is the most unpredictable and complicated failure mode, which may cause disastrous consequences. This paper presents safety analysis and constraint detection techniques for process interaction errors among hardware, software, and human processes. Among interaction errors, the most dreadful ones are those that involve run-time misinterpretation from a logic process. We call them the 'semantic interaction errors'. Such abnormal interaction is not adequately emphasized in current research. In our static analysis, we provide a fault tree template focusing on semantic interaction errors by checking conflicting pre-conditions and post-conditions among interacting processes. Thus, far-fetched, but highly risky, interaction scenarios involve interpretation errors can be identified. For run-time monitoring, a range of constraint types is proposed for checking abnormal signs at run time. We extend current constraints to a broader relational level and a global level, considering process/device dependencies and physical conservation rules in order to detect process interaction errors. The proposed techniques can reduce abnormal interactions; they can also be used to assist in safety-case construction.

Using a Delphi Method to Identify Human Factors Contributing to Nursing Errors.

Science.gov (United States)

Roth, Cheryl; Brewer, Melanie; Wieck, K Lynn

2017-07-01

The purpose of this study was to identify human factors associated with nursing errors. Using a Delphi technique, this study used feedback from a panel of nurse experts (n = 25) on an initial qualitative survey questionnaire followed by summarizing the results with feedback and confirmation. Synthesized factors regarding causes of errors were incorporated into a quantitative Likert-type scale, and the original expert panel participants were queried a second time to validate responses. The list identified 24 items as most common causes of nursing errors, including swamping and errors made by others that nurses are expected to recognize and fix. The responses provided a consensus top 10 errors list based on means with heavy workload and fatigue at the top of the list. The use of the Delphi survey established consensus and developed a platform upon which future study of nursing errors can evolve as a link to future solutions. This list of human factors in nursing errors should serve to stimulate dialogue among nurses about how to prevent errors and improve outcomes. Human and system failures have been the subject of an abundance of research, yet nursing errors continue to occur. © 2016 Wiley Periodicals, Inc.

Human factor analysis and preventive countermeasures in nuclear power plant

International Nuclear Information System (INIS)

Li Ye

2010-01-01

Based on the human error analysis theory and the characteristics of maintenance in a nuclear power plant, human factors of maintenance in NPP are divided into three different areas: human, technology, and organization. Which is defined as individual factors, including psychological factors, physiological characteristics, health status, level of knowledge and interpersonal skills; The technical factors including technology, equipment, tools, working order, etc.; The organizational factors including management, information exchange, education, working environment, team building and leadership management,etc The analysis found that organizational factors can directly or indirectly affect the behavior of staff and technical factors, is the most basic human error factor. Based on this nuclear power plant to reduce human error and measures the response. (authors)

Identification and Assessment of Human Errors in Postgraduate Endodontic Students of Kerman University of Medical Sciences by Using the SHERPA Method

Directory of Open Access Journals (Sweden)

Saman Dastaran

2016-03-01

Full Text Available Introduction: Human errors are the cause of many accidents, including industrial and medical, therefore finding out an approach for identifying and reducing them is very important. Since no study has been done about human errors in the dental field, this study aimed to identify and assess human errors in postgraduate endodontic students of Kerman University of Medical Sciences by using the SHERPA Method. Methods: This cross-sectional study was performed during year 2014. Data was collected using task observation and interviewing postgraduate endodontic students. Overall, 10 critical tasks, which were most likely to cause harm to patients were determined. Next, Hierarchical Task Analysis (HTA was conducted and human errors in each task were identified by the Systematic Human Error Reduction Prediction Approach (SHERPA technique worksheets. Results: After analyzing the SHERPA worksheets, 90 human errors were identified including (67.7% action errors, (13.3% checking errors, (8.8% selection errors, (5.5% retrieval errors and (4.4% communication errors. As a result, most of them were action errors and less of them were communication errors. Conclusions: The results of the study showed that the highest percentage of errors and the highest level of risk were associated with action errors, therefore, to reduce the occurrence of such errors and limit their consequences, control measures including periodical training of work procedures, providing work check-lists, development of guidelines and establishment of a systematic and standardized reporting system, should be put in place. Regarding the results of this study, the control of recovery errors with the highest percentage of undesirable risk and action errors with the highest frequency of errors should be in the priority of control

Human Error and the International Space Station: Challenges and Triumphs in Science Operations

Science.gov (United States)

Harris, Samantha S.; Simpson, Beau C.

2016-01-01

Any system with a human component is inherently risky. Studies in human factors and psychology have repeatedly shown that human operators will inevitably make errors, regardless of how well they are trained. Onboard the International Space Station (ISS) where crew time is arguably the most valuable resource, errors by the crew or ground operators can be costly to critical science objectives. Operations experts at the ISS Payload Operations Integration Center (POIC), located at NASA's Marshall Space Flight Center in Huntsville, Alabama, have learned that from payload concept development through execution, there are countless opportunities to introduce errors that can potentially result in costly losses of crew time and science. To effectively address this challenge, we must approach the design, testing, and operation processes with two specific goals in mind. First, a systematic approach to error and human centered design methodology should be implemented to minimize opportunities for user error. Second, we must assume that human errors will be made and enable rapid identification and recoverability when they occur. While a systematic approach and human centered development process can go a long way toward eliminating error, the complete exclusion of operator error is not a reasonable expectation. The ISS environment in particular poses challenging conditions, especially for flight controllers and astronauts. Operating a scientific laboratory 250 miles above the Earth is a complicated and dangerous task with high stakes and a steep learning curve. While human error is a reality that may never be fully eliminated, smart implementation of carefully chosen tools and techniques can go a long way toward minimizing risk and increasing the efficiency of NASA's space science operations.

An assessment of the risk significance of human errors in selected PSAs and operating events

International Nuclear Information System (INIS)

Palla, R.L. Jr.; El-Bassioni, A.

1991-01-01

Sensitivity studies based on Probabilistic Safety Assessments (PSAs) for a pressurized water reactor and a boiling water reactor are described. In each case human errors modeled in the PSAs were categorized according to such factors as error type, location, timing, and plant personnel involved. Sensitivity studies were then conducted by varying the error rates in each category and evaluating the corresponding change in total core damage frequency and accident sequence frequency. Insights obtained are discussed and reasons for differences in risk sensitivity between plants are explored. A separate investigation into the role of human error in risk-important operating events is also described. This investigation involved the analysis of data from the USNRC Accident Sequence Precursor program to determine the effect of operator-initiated events on accident precursor trends, and to determine whether improved training can be correlated to current trends. The findings of this study are also presented. 5 refs., 15 figs., 1 tab

An Error Analysis on TFL Learners’ Writings

Directory of Open Access Journals (Sweden)

Arif ÇERÇİ

2016-12-01

Full Text Available The main purpose of the present study is to identify and represent TFL learners’ writing errors through error analysis. All the learners started learning Turkish as foreign language with A1 (beginner level and completed the process by taking C1 (advanced certificate in TÖMER at Gaziantep University. The data of the present study were collected from 14 students’ writings in proficiency exams for each level. The data were grouped as grammatical, syntactic, spelling, punctuation, and word choice errors. The ratio and categorical distributions of identified errors were analyzed through error analysis. The data were analyzed through statistical procedures in an effort to determine whether error types differ according to the levels of the students. The errors in this study are limited to the linguistic and intralingual developmental errors

Teacher knowledge of error analysis in differential calculus

Directory of Open Access Journals (Sweden)

Eunice K. Moru

2014-12-01

Full Text Available The study investigated teacher knowledge of error analysis in differential calculus. Two teachers were the sample of the study: one a subject specialist and the other a mathematics education specialist. Questionnaires and interviews were used for data collection. The findings of the study reflect that the teachers’ knowledge of error analysis was characterised by the following assertions, which are backed up with some evidence: (1 teachers identified the errors correctly, (2 the generalised error identification resulted in opaque analysis, (3 some of the identified errors were not interpreted from multiple perspectives, (4 teachers’ evaluation of errors was either local or global and (5 in remedying errors accuracy and efficiency were emphasised more than conceptual understanding. The implications of the findings of the study for teaching include engaging in error analysis continuously as this is one way of improving knowledge for teaching.

Inclusion of task dependence in human reliability analysis

International Nuclear Information System (INIS)

Su, Xiaoyan; Mahadevan, Sankaran; Xu, Peida; Deng, Yong

2014-01-01

Dependence assessment among human errors in human reliability analysis (HRA) is an important issue, which includes the evaluation of the dependence among human tasks and the effect of the dependence on the final human error probability (HEP). This paper represents a computational model to handle dependence in human reliability analysis. The aim of the study is to automatically provide conclusions on the overall degree of dependence and calculate the conditional human error probability (CHEP) once the judgments of the input factors are given. The dependence influencing factors are first identified by the experts and the priorities of these factors are also taken into consideration. Anchors and qualitative labels are provided as guidance for the HRA analyst's judgment of the input factors. The overall degree of dependence between human failure events is calculated based on the input values and the weights of the input factors. Finally, the CHEP is obtained according to a computing formula derived from the technique for human error rate prediction (THERP) method. The proposed method is able to quantify the subjective judgment from the experts and improve the transparency in the HEP evaluation process. Two examples are illustrated to show the effectiveness and the flexibility of the proposed method. - Highlights: • We propose a computational model to handle dependence in human reliability analysis. • The priorities of the dependence influencing factors are taken into consideration. • The overall dependence degree is determined by input judgments and the weights of factors. • The CHEP is obtained according to a computing formula derived from THERP

Trend analysis of nuclear reactor automatic trip events subjected to operator's human error at United States nuclear power plants

International Nuclear Information System (INIS)

Takagawa, Kenichi

2009-01-01

Trends in nuclear reactor automatic trip events due to human errors during plant operating mode have been analyzed by extracting 20 events which took place in the United States during the period of seven years from 2002 to 2008, cited in the LERs (Licensee Event Reports) submitted to the US Nuclear Regulatory Commission (NRC). It was shown that the yearly number of events was relatively large before 2005, and thereafter the number decreased. A period of stable operation, in which the yearly number was kept very small, continued for about three years, and then the yearly number turned to increase again. Before 2005, automatic trip events occurred more frequently during periodic inspections or start-up/shut-down operations. The recent trends, however, indicate that trip events became more frequent due to human errors during daily operations. Human errors were mostly caused by the self-conceit and carelessness of operators through the whole period. The before mentioned trends in the yearly number of events might be explained as follows. The decrease in the automatic trip events is attributed to sharing trouble information, leading as a consequence to improvement of the manual and training for the operations which have a higher potential risk of automatic trip. Then, while the period of stable operation continued, some operators came to pay less attention to preventing human errors and not interest in the training, leading to automatic trip events in reality due to miss-operation. From these analyses on trouble experiences in the US, we learnt the followings to prevent the occurrence similar troubles in Japan: Operators should be thoroughly skilled in basic actions to prevent human errors as persons concerned. And it should be further emphasized that they should elaborate by imaging actual plant operations even though the simulator training gives them successful experiences. (author)

SLIM-MAUD: an approach to assessing human error probabilities using structured expert judgment. Volume II. Detailed analysis of the technical issues

International Nuclear Information System (INIS)

Embrey, D.E.; Humphreys, P.; Rosa, E.A.; Kirwan, B.; Rea, K.

1984-07-01

This two-volume report presents the procedures and analyses performed in developing an approach for structuring expert judgments to estimate human error probabilities. Volume I presents an overview of work performed in developing the approach: SLIM-MAUD (Success Likelihood Index Methodology, implemented through the use of an interactive computer program called MAUD-Multi-Attribute Utility Decomposition). Volume II provides a more detailed analysis of the technical issues underlying the approach

ATHEANA: open-quotes a technique for human error analysisclose quotes entering the implementation phase

International Nuclear Information System (INIS)

Taylor, J.; O'Hara, J.; Luckas, W.

1997-01-01

Probabilistic Risk Assessment (PRA) has become an increasingly important tool in the nuclear power industry, both for the Nuclear Regulatory Commission (NRC) and the operating utilities. The NRC recently published a final policy statement, SECY-95-126, encouraging the use of PRA in regulatory activities. Human reliability analysis (HRA), while a critical element of PRA, has limitations in the analysis of human actions in PRAs that have long been recognized as a constraint when using PRA. In fact, better integration of HRA into the PRA process has long been a NRC issue. Of particular concern, has been the omission of errors of commission - those errors that are associated with inappropriate interventions by operators with operating systems. To address these concerns, the NRC identified the need to develop an improved HRA method, so that human reliability can be better represented and integrated into PRA modeling and quantification. The purpose of the Brookhaven National Laboratory (BNL) project, entitled 'Improved HRA Method Based on Operating Experience' is to develop a new method for HRA which is supported by the analysis of risk-significant operating experience. This approach will allow a more realistic assessment and representation of the human contribution to plant risk, and thereby increase the utility of PRA. The project's completed, ongoing, and future efforts fall into four phases: (1) Assessment phase (FY 92/93); (2) Analysis and Characterization phase (FY 93/94); (3) Development phase (FY 95/96); and (4) Implementation phase (FY 96/97 ongoing)

Multiple sequential failure model: A probabilistic approach to quantifying human error dependency

International Nuclear Information System (INIS)

Samanta

1985-01-01

This paper rpesents a probabilistic approach to quantifying human error dependency when multiple tasks are performed. Dependent human failures are dominant contributors to risks from nuclear power plants. An overview of the Multiple Sequential Failure (MSF) model developed and its use in probabilistic risk assessments (PRAs) depending on the available data are discussed. A small-scale psychological experiment was conducted on the nature of human dependency and the interpretation of the experimental data by the MSF model show remarkable accommodation of the dependent failure data. The model, which provides an unique method for quantification of dependent failures in human reliability analysis, can be used in conjunction with any of the general methods currently used for performing the human reliability aspect in PRAs

Sensitivity of risk parameters to human errors in reactor safety study for a PWR

International Nuclear Information System (INIS)

Samanta, P.K.; Hall, R.E.; Swoboda, A.L.

1981-01-01

Sensitivities of the risk parameters, emergency safety system unavailabilities, accident sequence probabilities, release category probabilities and core melt probability were investigated for changes in the human error rates within the general methodological framework of the Reactor Safety Study (RSS) for a Pressurized Water Reactor (PWR). Impact of individual human errors were assessed both in terms of their structural importance to core melt and reliability importance on core melt probability. The Human Error Sensitivity Assessment of a PWR (HESAP) computer code was written for the purpose of this study. The code employed point estimate approach and ignored the smoothing technique applied in RSS. It computed the point estimates for the system unavailabilities from the median values of the component failure rates and proceeded in terms of point values to obtain the point estimates for the accident sequence probabilities, core melt probability, and release category probabilities. The sensitivity measure used was the ratio of the top event probability before and after the perturbation of the constituent events. Core melt probability per reactor year showed significant increase with the increase in the human error rates, but did not show similar decrease with the decrease in the human error rates due to the dominance of the hardware failures. When the Minimum Human Error Rate (M.H.E.R.) used is increased to 10 -3 , the base case human error rates start sensitivity to human errors. This effort now allows the evaluation of new error rate data along with proposed changes in the man machine interface

Comparative evaluation of three cognitive error analysis methods through an application to accident management tasks in NPPs

International Nuclear Information System (INIS)

Jung, Won Dea; Kim, Jae Whan; Ha, Jae Joo; Yoon, Wan C.

1999-01-01

This study was performed to comparatively evaluate selected Human Reliability Analysis (HRA) methods which mainly focus on cognitive error analysis, and to derive the requirement of a new human error analysis (HEA) framework for Accident Management (AM) in nuclear power plants(NPPs). In order to achieve this goal, we carried out a case study of human error analysis on an AM task in NPPs. In the study we evaluated three cognitive HEA methods, HRMS, CREAM and PHECA, which were selected through the review of the currently available seven cognitive HEA methods. The task of reactor cavity flooding was chosen for the application study as one of typical tasks of AM in NPPs. From the study, we derived seven requirement items for a new HEA method of AM in NPPs. We could also evaluate the applicability of three cognitive HEA methods to AM tasks. CREAM is considered to be more appropriate than others for the analysis of AM tasks. But, PHECA is regarded less appropriate for the predictive HEA technique as well as for the analysis of AM tasks. In addition to these, the advantages and disadvantages of each method are described. (author)

The Countermeasures against the Human Errors in Nuclear Power Plants

International Nuclear Information System (INIS)

Lee, Yong Hee; Kwon, Ki Chun; Lee, Jung Woon; Lee, Hyun; Jang, Tong Il

2009-10-01

Due to human error, the failure of nuclear power facilities essential for the prevention of accidents and related research in ergonomics and human factors, including the long term, comprehensive measures are considered technology is urgently required. Past nuclear facilities for the hardware in terms of continuing interest over subsequent definite improvement even have brought, now a nuclear facility to engage in people-related human factors for attention by nuclear facilities, ensuring the safety of its economic and industrial aspects. The point of the improvement is urgently required. The purpose of this research, including nuclear power plants in various nuclear facilities to minimize the possibility of human error by ensuring the safety for human engineering aspects will be implemented in the medium and long term preventive measures is to establish comprehensive

The Countermeasures against the Human Errors in Nuclear Power Plants

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Kwon, Ki Chun; Lee, Jung Woon; Lee, Hyun; Jang, Tong Il

2009-10-15

Due to human error, the failure of nuclear power facilities essential for the prevention of accidents and related research in ergonomics and human factors, including the long term, comprehensive measures are considered technology is urgently required. Past nuclear facilities for the hardware in terms of continuing interest over subsequent definite improvement even have brought, now a nuclear facility to engage in people-related human factors for attention by nuclear facilities, ensuring the safety of its economic and industrial aspects. The point of the improvement is urgently required. The purpose of this research, including nuclear power plants in various nuclear facilities to minimize the possibility of human error by ensuring the safety for human engineering aspects will be implemented in the medium and long term preventive measures is to establish comprehensive.

Human reliability analysis of control room operators

Energy Technology Data Exchange (ETDEWEB)

Santos, Isaac J.A.L.; Carvalho, Paulo Victor R.; Grecco, Claudio H.S. [Instituto de Engenharia Nuclear (IEN), Rio de Janeiro, RJ (Brazil)

2005-07-01

Human reliability is the probability that a person correctly performs some system required action in a required time period and performs no extraneous action that can degrade the system Human reliability analysis (HRA) is the analysis, prediction and evaluation of work-oriented human performance using some indices as human error likelihood and probability of task accomplishment. Significant progress has been made in the HRA field during the last years, mainly in nuclear area. Some first-generation HRA methods were developed, as THERP (Technique for human error rate prediction). Now, an array of called second-generation methods are emerging as alternatives, for instance ATHEANA (A Technique for human event analysis). The ergonomics approach has as tool the ergonomic work analysis. It focus on the study of operator's activities in physical and mental form, considering at the same time the observed characteristics of operator and the elements of the work environment as they are presented to and perceived by the operators. The aim of this paper is to propose a methodology to analyze the human reliability of the operators of industrial plant control room, using a framework that includes the approach used by ATHEANA, THERP and the work ergonomics analysis. (author)

Fifty Years of THERP and Human Reliability Analysis

Energy Technology Data Exchange (ETDEWEB)

Ronald L. Boring

2012-06-01

In 1962 at a Human Factors Society symposium, Alan Swain presented a paper introducing a Technique for Human Error Rate Prediction (THERP). This was followed in 1963 by a Sandia Laboratories monograph outlining basic human error quantification using THERP and, in 1964, by a special journal edition of Human Factors on quantification of human performance. Throughout the 1960s, Swain and his colleagues focused on collecting human performance data for the Sandia Human Error Rate Bank (SHERB), primarily in connection with supporting the reliability of nuclear weapons assembly in the US. In 1969, Swain met with Jens Rasmussen of Risø National Laboratory and discussed the applicability of THERP to nuclear power applications. By 1975, in WASH-1400, Swain had articulated the use of THERP for nuclear power applications, and the approach was finalized in the watershed publication of the NUREG/CR-1278 in 1983. THERP is now 50 years old, and remains the most well known and most widely used HRA method. In this paper, the author discusses the history of THERP, based on published reports and personal communication and interviews with Swain. The author also outlines the significance of THERP. The foundations of human reliability analysis are found in THERP: human failure events, task analysis, performance shaping factors, human error probabilities, dependence, event trees, recovery, and pre- and post-initiating events were all introduced in THERP. While THERP is not without its detractors, and it is showing signs of its age in the face of newer technological applications, the longevity of THERP is a testament of its tremendous significance. THERP started the field of human reliability analysis. This paper concludes with a discussion of THERP in the context of newer methods, which can be seen as extensions of or departures from Swain’s pioneering work.

Fault tree model of human error based on error-forcing contexts

International Nuclear Information System (INIS)

Kang, Hyun Gook; Jang, Seung Cheol; Ha, Jae Joo

2004-01-01

In the safety-critical systems such as nuclear power plants, the safety-feature actuation is fully automated. In emergency case, the human operator could also play the role of a backup for automated systems. That is, the failure of safety-feature-actuation signal generation implies the concurrent failure of automated systems and that of manual actuation. The human operator's manual actuation failure is largely affected by error-forcing contexts (EFC). The failures of sensors and automated systems are most important ones. The sensors, the automated actuation system and the human operators are correlated in a complex manner and hard to develop a proper model. In this paper, we will explain the condition-based human reliability assessment (CBHRA) method in order to treat these complicated conditions in a practical way. In this study, we apply the CBHRA method to the manual actuation of safety features such as reactor trip and safety injection in Korean Standard Nuclear Power Plants

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... and characteristics of verbal communication errors such as handover errors and error during teamwork. Results Raters found description of verbal communication errors in 44 reports (52%). These included handover errors (35 (86%)), communication errors between different staff groups (19 (43%)), misunderstandings (13...... (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between...

The psychological background about human error and safety in NPP

International Nuclear Information System (INIS)

Zhang Li

1992-01-01

A human error is one of the factors which cause an accident in NPP. The in-situ psychological background plays an important role in inducing it. The author analyzes the structure of one's psychological background when one is at work, and gives a few examples of typical psychological background resulting in human errors. Finally it points out that the fundamental way to eliminate the unfavourable psychological background of safety production is to establish the safety culture in NPP along with its characteristics

Task Decomposition in Human Reliability Analysis

Energy Technology Data Exchange (ETDEWEB)

Boring, Ronald Laurids [Idaho National Laboratory; Joe, Jeffrey Clark [Idaho National Laboratory

2014-06-01

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approaches should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down— defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications.

Selection of the important performance influencing factors for the assessment of human error under accident management situations in nuclear power plants

International Nuclear Information System (INIS)

Kim, J. H.; Jung, W. J.

1999-01-01

This paper introduces the process and final results of selection of the important Performance Influencing Factors (PIFs) under emergency operation and accident management situations in nuclear power plants for use in the assessment of human errors. We collected two types of PIF taxonomies, one is the full set PIF list mainly developed for human error analysis, and the other is the PIFs for human reliability analysis (HRA) in probabilistic safety assessment (PSA). 5 PIF taxonomies among the full set PIF list and 10 PIF taxonomies among HRA methodologies (CREAM, SLIM, INTENT, were collected in this research. By reviewing and analyzing PIFs selected for HRA methodologies, the criterion could be established for the selection of appropriate PIFs under emergency operation and accident management situations. Based on this selection criteria, a new PIF taxonomy was proposed for the assessment of human error under emergency operation and accident management situations in nuclear power plants

An Error Analysis of Structured Light Scanning of Biological Tissue

DEFF Research Database (Denmark)

Jensen, Sebastian Hoppe Nesgaard; Wilm, Jakob; Aanæs, Henrik

2017-01-01

This paper presents an error analysis and correction model for four structured light methods applied to three common types of biological tissue; skin, fat and muscle. Despite its many advantages, structured light is based on the assumption of direct reflection at the object surface only......, statistical linear model based on the scan geometry. As such, scans can be corrected without introducing any specially designed pattern strategy or hardware. We can effectively reduce the error in a structured light scanner applied to biological tissue by as much as factor of two or three........ This assumption is violated by most biological material e.g. human skin, which exhibits subsurface scattering. In this study, we find that in general, structured light scans of biological tissue deviate significantly from the ground truth. We show that a large portion of this error can be predicted with a simple...

Human reliability assessment in a 99Mo/99mTc generator production facility using the standardized plant analysis risk-human (SPAR-H) technique.

Science.gov (United States)

Eyvazlou, Meysam; Dadashpour Ahangar, Ali; Rahimi, Azin; Davarpanah, Mohammad Reza; Sayyahi, Seyed Soheil; Mohebali, Mehdi

2018-02-13

Reducing human error is an important factor for enhancing safety protocols in various industries. Hence, analysis of the likelihood of human error in nuclear industries such as radiopharmaceutical production facilities has become more essential. This cross-sectional descriptive study was conducted to quantify the probability of human errors in a 99 Mo/ 99m Tc generator production facility in Iran. First, through expert interviews, the production process of the 99 Mo/ 99m Tc generator was analyzed using hierarchical task analysis (HTA). The standardized plant analysis risk-human (SPAR-H) method was then applied in order to calculate the probability of human error. Twenty tasks were determined using HTA. All of the eight performance shaping factors (PSF S ) were evaluated for the tasks. The mean probability of human error was 0.320. The highest and the lowest probability of human error in the 99 Mo/ 99m Tc generator production process, related to the 'loading the generator with the molybdenum solution' task and the 'generator elution' task, were 0.858 and 0.059, respectively. Required measures for reducing the human error probability (HEP) were suggested. These measures were derived from the level of PSF S that were evaluated in this study.

Human reliability analysis for probabilistic safety assessments - review of methods and issues

International Nuclear Information System (INIS)

Srinivas, G.; Guptan, Rajee; Malhotra, P.K.; Ghadge, S.G.; Chandra, Umesh

2011-01-01

It is well known that the two major events in World Nuclear Power Plant Operating history, namely the Three Mile Island and Chernobyl, were Human failure events. Subsequent to these two events, several significant changes have been incorporated in Plant Design, Control Room Design and Operator Training to reduce the possibility of Human errors during plant transients. Still, human error contribution to Risk in Nuclear Power Plant operations has been a topic of continued attention for research, development and analysis. Probabilistic Safety Assessments attempt to capture all potential human errors with a scientifically computed failure probability, through Human Reliability Analysis. Several methods are followed by different countries to quantify the Human error probability. This paper reviews the various popular methods being followed, critically examines them with reference to their criticisms and brings out issues for future research. (author)

Human medial frontal cortex activity predicts learning from errors.

Science.gov (United States)

Hester, Robert; Barre, Natalie; Murphy, Kevin; Silk, Tim J; Mattingley, Jason B

2008-08-01

Learning from errors is a critical feature of human cognition. It underlies our ability to adapt to changing environmental demands and to tune behavior for optimal performance. The posterior medial frontal cortex (pMFC) has been implicated in the evaluation of errors to control behavior, although it has not previously been shown that activity in this region predicts learning from errors. Using functional magnetic resonance imaging, we examined activity in the pMFC during an associative learning task in which participants had to recall the spatial locations of 2-digit targets and were provided with immediate feedback regarding accuracy. Activity within the pMFC was significantly greater for errors that were subsequently corrected than for errors that were repeated. Moreover, pMFC activity during recall errors predicted future responses (correct vs. incorrect), despite a sizeable interval (on average 70 s) between an error and the next presentation of the same recall probe. Activity within the hippocampus also predicted future performance and correlated with error-feedback-related pMFC activity. A relationship between performance expectations and pMFC activity, in the absence of differing reinforcement value for errors, is consistent with the idea that error-related pMFC activity reflects the extent to which an outcome is "worse than expected."

Error estimation in plant growth analysis

Directory of Open Access Journals (Sweden)

Andrzej Gregorczyk

2014-01-01

Full Text Available The scheme is presented for calculation of errors of dry matter values which occur during approximation of data with growth curves, determined by the analytical method (logistic function and by the numerical method (Richards function. Further formulae are shown, which describe absolute errors of growth characteristics: Growth rate (GR, Relative growth rate (RGR, Unit leaf rate (ULR and Leaf area ratio (LAR. Calculation examples concerning the growth course of oats and maize plants are given. The critical analysis of the estimation of obtained results has been done. The purposefulness of joint application of statistical methods and error calculus in plant growth analysis has been ascertained.

An experimental approach to validating a theory of human error in complex systems

Science.gov (United States)

Morris, N. M.; Rouse, W. B.

1985-01-01

The problem of 'human error' is pervasive in engineering systems in which the human is involved. In contrast to the common engineering approach of dealing with error probabilistically, the present research seeks to alleviate problems associated with error by gaining a greater understanding of causes and contributing factors from a human information processing perspective. The general approach involves identifying conditions which are hypothesized to contribute to errors, and experimentally creating the conditions in order to verify the hypotheses. The conceptual framework which serves as the basis for this research is discussed briefly, followed by a description of upcoming research. Finally, the potential relevance of this research to design, training, and aiding issues is discussed.

Analysis of human performance in KHNP NPPs

International Nuclear Information System (INIS)

Tae, Sung Eun

2004-01-01

The most important thing in the management of nuclear power plant is safety. One of the key factors to enhance the safety is to analyze human performance and to reflect the results on the practical plant operation. KHNP NPPs experienced human errors in the fields of operation and maintenance. The human errors need to be analyzed and, necessary corrective actions according to the causes should be made to prevent the same event or similar events. Therefore we'd like to introduce the procedure of K-HPES(KHNP-Human Performance Enhancement System) and the results of analysis of HPES reports produced in 2002 and 2003

Technical Note: Introduction of variance component analysis to setup error analysis in radiotherapy

Energy Technology Data Exchange (ETDEWEB)

Matsuo, Yukinori, E-mail: ymatsuo@kuhp.kyoto-u.ac.jp; Nakamura, Mitsuhiro; Mizowaki, Takashi; Hiraoka, Masahiro [Department of Radiation Oncology and Image-applied Therapy, Kyoto University, 54 Shogoin-Kawaharacho, Sakyo, Kyoto 606-8507 (Japan)

2016-09-15

Purpose: The purpose of this technical note is to introduce variance component analysis to the estimation of systematic and random components in setup error of radiotherapy. Methods: Balanced data according to the one-factor random effect model were assumed. Results: Analysis-of-variance (ANOVA)-based computation was applied to estimate the values and their confidence intervals (CIs) for systematic and random errors and the population mean of setup errors. The conventional method overestimates systematic error, especially in hypofractionated settings. The CI for systematic error becomes much wider than that for random error. The ANOVA-based estimation can be extended to a multifactor model considering multiple causes of setup errors (e.g., interpatient, interfraction, and intrafraction). Conclusions: Variance component analysis may lead to novel applications to setup error analysis in radiotherapy.

Technical Note: Introduction of variance component analysis to setup error analysis in radiotherapy

International Nuclear Information System (INIS)

Matsuo, Yukinori; Nakamura, Mitsuhiro; Mizowaki, Takashi; Hiraoka, Masahiro

2016-01-01

Purpose: The purpose of this technical note is to introduce variance component analysis to the estimation of systematic and random components in setup error of radiotherapy. Methods: Balanced data according to the one-factor random effect model were assumed. Results: Analysis-of-variance (ANOVA)-based computation was applied to estimate the values and their confidence intervals (CIs) for systematic and random errors and the population mean of setup errors. The conventional method overestimates systematic error, especially in hypofractionated settings. The CI for systematic error becomes much wider than that for random error. The ANOVA-based estimation can be extended to a multifactor model considering multiple causes of setup errors (e.g., interpatient, interfraction, and intrafraction). Conclusions: Variance component analysis may lead to novel applications to setup error analysis in radiotherapy.

Human error probability quantification using fuzzy methodology in nuclear plants

International Nuclear Information System (INIS)

Nascimento, Claudio Souza do

2010-01-01

This work obtains Human Error Probability (HEP) estimates from operator's actions in response to emergency situations a hypothesis on Research Reactor IEA-R1 from IPEN. It was also obtained a Performance Shaping Factors (PSF) evaluation in order to classify them according to their influence level onto the operator's actions and to determine these PSF actual states over the plant. Both HEP estimation and PSF evaluation were done based on Specialists Evaluation using interviews and questionnaires. Specialists group was composed from selected IEA-R1 operators. Specialist's knowledge representation into linguistic variables and group evaluation values were obtained through Fuzzy Logic and Fuzzy Set Theory. HEP obtained values show good agreement with literature published data corroborating the proposed methodology as a good alternative to be used on Human Reliability Analysis (HRA). (author)

Failures without errors: quantification of context in HRA

International Nuclear Information System (INIS)

Fujita, Yushi; Hollnagel, Erik

2004-01-01

PSA-cum-human reliability analysis (HRA) has traditionally used individual human actions, hence individual 'human errors', as a meaningful unit of analysis. This is inconsistent with the current understanding of accidents, which points out that the notion of 'human error' is ill defined and that adverse events more often are the due to the working conditions than to people. Several HRA approaches, such as ATHEANA and CREAM have recognised this conflict and proposed ways to deal with it. This paper describes an improvement of the basic screening method in CREAM, whereby a rating of the performance conditions can be used to calculate a Mean Failure Rate directly without invoking the notion of human error

Human reliability analysis data obtainment through fuzzy logic in nuclear plants

International Nuclear Information System (INIS)

Nascimento, C.S. do; Mesquita, R.N. de

2012-01-01

Highlights: ► Human Error Probability estimates from operator's reactions to emergency situations. ► Human Reliability Analysis input data obtainment through fuzzy logic inference. ► Performance Shaping Factors evaluation influence level onto the operator's actions. - Abstract: Human error has been recognized as an important factor for many industrial and nuclear accidents occurrence. Human error data is scarcely available for different reasons among which, lapses in historical database registry methodology is an important one. Human Reliability Analysis (HRA) is an usual tool employed to estimate the probability that an operator will reasonably perform a system required task in required time without degrading the system. This meta-analysis requires specific Human Error Probability estimates for most of its procedure. This work obtains Human Error Probability (HEP) estimates from operator's actions in response to emergency situations hypothesis on Research Reactor IEA-R1 from IPEN, Brazil. Through this proposed methodology HRA should be able to be performed even with shortage of related human error statistical data. A Performance Shaping Factors (PSF's) evaluation in order to classify and estimate their influence level onto the operator's actions and to determine their actual state over the plant was also done. Both HEP estimation and PSF evaluation were done based on expert judgment using interviews and questionnaires. Expert group was established based on selected IEA-R1 operators, and their evaluation were put into a knowledge representation system which used linguistic variables and group evaluation values that were obtained through Fuzzy Logic and Fuzzy Set theory. HEP obtained values show good agreement with literature published data corroborating the proposed methodology as a good alternative to be used on HRA.

An Empirical Study on Human Performance according to the Physical Environment (Potential Human Error Hazard) in Nuclear Power Plants

International Nuclear Information System (INIS)

Kim, Ar Ryum; Jang, In Seok; Seong, Proong Hyun

2014-01-01

The management of the physical environment for safety is more effective than a nuclear industry. Despite the physical environment such as lighting, noise satisfy with management standards, it can be background factors may cause human error and affect human performance. Because the consequence of extremely human error and human performance is high according to the physical environment, requirement standard could be covered with specific criteria. Particularly, in order to avoid human errors caused by an extremely low or rapidly-changing intensity illumination and masking effect such as power disconnection, plans for better visual environment and better function performances should be made as a careful study on efficient ways to manage and continue the better conditions is conducted

Effective use of pre-job briefing as tool for the prevention of human error

International Nuclear Information System (INIS)

Schlump, Ansgar

2015-01-01

There is a fundamental demand to minimise the risks for workers and facilities while executing maintenance work. To ensure that facilities are secure and reliable, any deviation from normal operation behaviour has to be avoided. Accurate planning is the basis for minimising mistakes and making work more secure. All workers involved should understand how the work should be done and what is expected to avoid human errors. Especially in nuclear power plants, the human performance tools (HPT) have proved to be an effective instrument to minimise human errors. These human performance tools consist of numerous different tools that complement each other (e.g. pre-job briefing). The safety culture of the plants is also characterised by these tools. The choice of using the right HP-Tool is often a difficult task for the work planer. On the one hand, he wants to avoid mistakes during the execution of work but on the other hand he does not want to irritate the workers with unnecessary requirements. The proposed concept uses a simple risk analysis to take into account the complexity of the task, the experience of the past and the consequences of failure in to account. One main result of this risk analysis is a recommendation of the detailing of the pre-job briefing, to reduce the risks for the involved staff to a minimum.

Human factor analysis and preventive countermeasures of maintenance in nuclear power plant

International Nuclear Information System (INIS)

Zhang Li; Hu Chao

2008-01-01

Based on the human error analysis theory and the characteristics of maintenance in a nuclear power plant, human factors of maintenance in NPP are divided into three different areas: human, technology, and organization, in which human refers to the individual factors, mainly including psychological quality, physiological characteristic, state of health, knowledge, skill level, and interpersonal relationship. Technology includes the maintenance technology, maintenance strategy, maintenance tool, maintenance interface, maintenance regulation, and work environment. Organization includes task arrangement, information communication, training, personnel external environment, team construction, and leadership. The analysis also reveals that the organization factors, which can indirectly influence personnel performance, are the primary initiators of human error. Based on these, some countermeasures are brought forward in order to reduce human errors. (authors)

Analysis of operational events by ATHEANA framework for human factor modelling

International Nuclear Information System (INIS)

Bedreaga, Luminita; Constntinescu, Cristina; Doca, Cezar; Guzun, Basarab

2007-01-01

In the area of human reliability assessment, the experts recognise the fact that the current methods have not represented correctly the role of human in prevention, initiating and mitigating the accidents in nuclear power plants. The nature of this deficiency appears because the current methods used in modelling of human factor have not taken into account the human performance and reliability such as it has been observed in the operational events. ATHEANA - A Technique for Human Error ANAlysis - is a new methodology for human analysis that has included the specific data of operational events and also psychological models for human behaviour. This method has included new elements such as the unsafe action and error mechanisms. In this paper we present the application of ATHEANA framework in the analysis of operational events that appeared in different nuclear power plants during 1979-2002. The analysis of operational events has consisted of: - identification of the unsafe actions; - including the unsafe actions into a category, omission ar commission; - establishing the type of error corresponding to the unsafe action: slip, lapse, mistake and circumvention; - establishing the influence of performance by shaping the factors and some corrective actions. (authors)

Human Factors Process Task Analysis: Liquid Oxygen Pump Acceptance Test Procedure at the Advanced Technology Development Center

Science.gov (United States)

Diorio, Kimberly A.; Voska, Ned (Technical Monitor)

2002-01-01

This viewgraph presentation provides information on Human Factors Process Failure Modes and Effects Analysis (HF PFMEA). HF PFMEA includes the following 10 steps: Describe mission; Define System; Identify human-machine; List human actions; Identify potential errors; Identify factors that effect error; Determine likelihood of error; Determine potential effects of errors; Evaluate risk; Generate solutions (manage error). The presentation also describes how this analysis was applied to a liquid oxygen pump acceptance test.

Comparison of risk sensitivity to human errors in the Oconee and LaSalle PRAs

International Nuclear Information System (INIS)

Wong, S.; Higgins, J.

1991-01-01

This paper describes the comparative analyses of plant risk sensitivity to human errors in the Oconee and La Salle Probabilistic Risk Assessment (PRAs). These analyses were performed to determine the reasons for the observed differences in the sensitivity of core melt frequency (CMF) to changes in human error probabilities (HEPs). Plant-specific design features, PRA methods, and the level of detail and assumptions in the human error modeling were evaluated to assess their influence risk estimates and sensitivities

Coping with human errors through system design: Implications for ecological interface design

DEFF Research Database (Denmark)

Rasmussen, Jens; Vicente, Kim J.

1989-01-01

Research during recent years has revealed that human errors are not stochastic events which can be removed through improved training programs or optimal interface design. Rather, errors tend to reflect either systematic interference between various models, rules, and schemata, or the effects...... of the adaptive mechanisms involved in learning. In terms of design implications, these findings suggest that reliable human-system interaction will be achieved by designing interfaces which tend to minimize the potential for control interference and support recovery from errors. In other words, the focus should...... be on control of the effects of errors rather than on the elimination of errors per se. In this paper, we propose a theoretical framework for interface design that attempts to satisfy these objectives. The goal of our framework, called ecological interface design, is to develop a meaningful representation...

Support of protective work of human error in a nuclear power plant

International Nuclear Information System (INIS)

Yoshizawa, Yuriko

1999-01-01

The nuclear power plant human factor group of the Tokyo Electric Power Co., Ltd. supports various protective work of human error conducted at the nuclear power plant. Its main researching theme are studies on human factor on operation of a nuclear power plant, and on recovery and common basic study on human factor. In addition, on a base of the obtained informations, assistance to protective work of human error conducted at the nuclear power plant as well as development for its actual use was also promoted. Especially, for actions sharing some dangerous informations, various assistances such as a proposal on actual example analytical method to effectively understand a dangerous information not facially but faithfully, construction of a data base to conveniently share such dangerous information, and practice on non-accident business survey for a hint of effective promotion of the protection work, were promoted. Here were introduced on assistance and investigation for effective sharing of the dangerous informations for various actions on protection of human error mainly conducted in nuclear power plant. (G.K.)

Frame-based safety analysis approach for decision-based errors

International Nuclear Information System (INIS)

Fan, Chin-Feng; Yihb, Swu

1997-01-01

A frame-based approach is proposed to analyze decision-based errors made by automatic controllers or human operators due to erroneous reference frames. An integrated framework, Two Frame Model (TFM), is first proposed to model the dynamic interaction between the physical process and the decision-making process. Two important issues, consistency and competing processes, are raised. Consistency between the physical and logic frames makes a TFM-based system work properly. Loss of consistency refers to the failure mode that the logic frame does not accurately reflect the state of the controlled processes. Once such failure occurs, hazards may arise. Among potential hazards, the competing effect between the controller and the controlled process is the most severe one, which may jeopardize a defense-in-depth design. When the logic and physical frames are inconsistent, conventional safety analysis techniques are inadequate. We propose Frame-based Fault Tree; Analysis (FFTA) and Frame-based Event Tree Analysis (FETA) under TFM to deduce the context for decision errors and to separately generate the evolution of the logical frame as opposed to that of the physical frame. This multi-dimensional analysis approach, different from the conventional correctness-centred approach, provides a panoramic view in scenario generation. Case studies using the proposed techniques are also given to demonstrate their usage and feasibility

Quality assurance and human error effects on the structural safety

International Nuclear Information System (INIS)

Bertero, R.; Lopez, R.; Sarrate, M.

1991-01-01

Statistical surveys show that the frequency of failure of structures is much larger than that expected by the codes. Evidence exists that human errors (especially during the design process) is the main cause for the difference between the failure probability admitted by codes and the reality. In this paper, the attenuation of human error effects using tools of quality assurance is analyzed. In particular, the importance of the independent design review is highlighted, and different approaches are discussed. The experience from the Atucha II project, as well as the USA and German practice on independent design review, are summarized. (Author)

Human error views : a framework for benchmarking organizations and measuring the distance between academia and industry

NARCIS (Netherlands)

Karanikas, Nektarios

2015-01-01

The paper presents a framework that through structured analysis of accident reports explores the differences between practice and academic literature as well amongst organizations regarding their views on human error. The framework is based on the hypothesis that the wording of accident reports

Operator errors

International Nuclear Information System (INIS)

Knuefer; Lindauer

1980-01-01

Besides that at spectacular events a combination of component failure and human error is often found. Especially the Rasmussen-Report and the German Risk Assessment Study show for pressurised water reactors that human error must not be underestimated. Although operator errors as a form of human error can never be eliminated entirely, they can be minimized and their effects kept within acceptable limits if a thorough training of personnel is combined with an adequate design of the plant against accidents. Contrary to the investigation of engineering errors, the investigation of human errors has so far been carried out with relatively small budgets. Intensified investigations in this field appear to be a worthwhile effort. (orig.)

Analysis of error patterns in clinical radiotherapy

International Nuclear Information System (INIS)

Macklis, Roger; Meier, Tim; Barrett, Patricia; Weinhous, Martin

1996-01-01

Purpose: Until very recently, prescription errors and adverse treatment events have rarely been studied or reported systematically in oncology. We wished to understand the spectrum and severity of radiotherapy errors that take place on a day-to-day basis in a high-volume academic practice and to understand the resource needs and quality assurance challenges placed on a department by rapid upswings in contract-based clinical volumes requiring additional operating hours, procedures, and personnel. The goal was to define clinical benchmarks for operating safety and to detect error-prone treatment processes that might function as 'early warning' signs. Methods: A multi-tiered prospective and retrospective system for clinical error detection and classification was developed, with formal analysis of the antecedents and consequences of all deviations from prescribed treatment delivery, no matter how trivial. A department-wide record-and-verify system was operational during this period and was used as one method of treatment verification and error detection. Brachytherapy discrepancies were analyzed separately. Results: During the analysis year, over 2000 patients were treated with over 93,000 individual fields. A total of 59 errors affecting a total of 170 individual treated fields were reported or detected during this period. After review, all of these errors were classified as Level 1 (minor discrepancy with essentially no potential for negative clinical implications). This total treatment delivery error rate (170/93, 332 or 0.18%) is significantly better than corresponding error rates reported for other hospital and oncology treatment services, perhaps reflecting the relatively sophisticated error avoidance and detection procedures used in modern clinical radiation oncology. Error rates were independent of linac model and manufacturer, time of day (normal operating hours versus late evening or early morning) or clinical machine volumes. There was some relationship to

Human reliability analysis data obtainment through fuzzy logic in nuclear plants

Energy Technology Data Exchange (ETDEWEB)

Nascimento, C.S. do, E-mail: claudio.souza@ctmsp.mar.mil.br [Centro Tecnologico da Marinha em Sao Paulo (CTMSP), Av. Professor Lineu Prestes 2468, 05508-000 Sao Paulo, SP (Brazil); Mesquita, R.N. de, E-mail: rnavarro@ipen.br [Instituto de Pesquisas Energeticas e Nucleares (IPEN/CNEN - SP), Av. Professor Lineu Prestes 2242, 05508-000 Sao Paulo, SP (Brazil)

2012-09-15

Highlights: Black-Right-Pointing-Pointer Human Error Probability estimates from operator's reactions to emergency situations. Black-Right-Pointing-Pointer Human Reliability Analysis input data obtainment through fuzzy logic inference. Black-Right-Pointing-Pointer Performance Shaping Factors evaluation influence level onto the operator's actions. - Abstract: Human error has been recognized as an important factor for many industrial and nuclear accidents occurrence. Human error data is scarcely available for different reasons among which, lapses in historical database registry methodology is an important one. Human Reliability Analysis (HRA) is an usual tool employed to estimate the probability that an operator will reasonably perform a system required task in required time without degrading the system. This meta-analysis requires specific Human Error Probability estimates for most of its procedure. This work obtains Human Error Probability (HEP) estimates from operator's actions in response to emergency situations hypothesis on Research Reactor IEA-R1 from IPEN, Brazil. Through this proposed methodology HRA should be able to be performed even with shortage of related human error statistical data. A Performance Shaping Factors (PSF's) evaluation in order to classify and estimate their influence level onto the operator's actions and to determine their actual state over the plant was also done. Both HEP estimation and PSF evaluation were done based on expert judgment using interviews and questionnaires. Expert group was established based on selected IEA-R1 operators, and their evaluation were put into a knowledge representation system which used linguistic variables and group evaluation values that were obtained through Fuzzy Logic and Fuzzy Set theory. HEP obtained values show good agreement with literature published data corroborating the proposed methodology as a good alternative to be used on HRA.

Research review and development trends of human reliability analysis techniques

International Nuclear Information System (INIS)

Li Pengcheng; Chen Guohua; Zhang Li; Dai Licao

2011-01-01

Human reliability analysis (HRA) methods are reviewed. The theoretical basis of human reliability analysis, human error mechanism, the key elements of HRA methods as well as the existing HRA methods are respectively introduced and assessed. Their shortcomings,the current research hotspot and difficult problems are identified. Finally, it takes a close look at the trends of human reliability analysis methods. (authors)

Self-assessment of human performance errors in nuclear operations

International Nuclear Information System (INIS)

Chambliss, K.V.

1996-01-01

One of the most important approaches to improving nuclear safety is to have an effective self-assessment process in place, whose cornerstone is the identification and improvement of human performance errors. Experience has shown that significant events usually have had precursors of human performance errors. If these precursors are left uncorrected or not understood, the symptoms recur and result in unanticipated events of greater safety significance. The Institute of Nuclear Power Operations (INPO) has been championing the cause of promoting excellence in human performance in the nuclear industry. INPO's report, open-quotes Excellence in Human Performance,close quotes emphasizes the importance of several factors that play a role in human performance. They include individual, supervisory, and organizational behaviors; real-time feedback that results in specific behavior to produce safe and reliable performance; and proactive measures that remove obstacles from excellent human performance. Zack Pate, chief executive officer and president of INPO, in his report, open-quotes The Control Room,close quotes provides an excellent discussion of serious events in the nuclear industry since 1994 and compares them with the results from a recent study by the National Transportation Safety Board of airline accidents in the 12-yr period from 1978 to 1990 to draw some common themes that relate to human performance issues in the control room

A Conceptual Framework for Predicting Error in Complex Human-Machine Environments

Science.gov (United States)

Freed, Michael; Remington, Roger; Null, Cynthia H. (Technical Monitor)

1998-01-01

We present a Goals, Operators, Methods, and Selection Rules-Model Human Processor (GOMS-MHP) style model-based approach to the problem of predicting human habit capture errors. Habit captures occur when the model fails to allocate limited cognitive resources to retrieve task-relevant information from memory. Lacking the unretrieved information, decision mechanisms act in accordance with implicit default assumptions, resulting in error when relied upon assumptions prove incorrect. The model helps interface designers identify situations in which such failures are especially likely.

A probabilistic analysis method to evaluate the effect of human factors on plant safety

International Nuclear Information System (INIS)

Ujita, H.

1987-01-01

A method to evaluate the effect of human factors on probabilistic safety analysis (PSA) is developed. The main features of the method are as follows: 1. A time-dependent multibranch tree is constructed to treat time dependency of human error probability. 2. A sensitivity analysis is done to determine uncertainty in the PSA due to branch time of human error occurrence, human error data source, extraneous act probability, and human recovery probability. The method is applied to a large-break, loss-of-coolant accident of a boiling water reactor-5. As a result, core melt probability and risk do not depend on the number of time branches, which means that a small number of branches are sufficient. These values depend on the first branch time and the human error probability

Error Analysis in Mathematics. Technical Report #1012

Science.gov (United States)

Lai, Cheng-Fei

2012-01-01

Error analysis is a method commonly used to identify the cause of student errors when they make consistent mistakes. It is a process of reviewing a student's work and then looking for patterns of misunderstanding. Errors in mathematics can be factual, procedural, or conceptual, and may occur for a number of reasons. Reasons why students make…

Development of a new cause classification method considering plant ageing and human errors for adverse events which occurred in nuclear power plants and some results of its application

International Nuclear Information System (INIS)

Miyazaki, Takamasa

2007-01-01

The adverse events which occurred in nuclear power plants are analyzed to prevent similar events, and in the analysis of each event, the cause of the event is classified by a cause classification method. This paper shows a new cause classification method which is improved in several points as follows: (1) the whole causes are systematically classified into three major categories such as machine system, operation system and plant outside causes, (2) the causes of the operation system are classified into several management errors normally performed in a nuclear power plant, (3) the content of ageing is defined in detail for their further analysis, (4) human errors are divided and defined by the error stage, (5) human errors can be related to background factors, and so on. This new method is applied to the adverse events which occurred in domestic and overseas nuclear power plants in 2005. From these results, it is clarified that operation system errors account for about 60% of the whole causes, of which approximately 60% are maintenance errors, about 40% are worker's human errors, and that the prevention of maintenance errors, especially worker's human errors is crucial. (author)

In-plant reliability data base for nuclear plant components: a feasibility study on human error information

International Nuclear Information System (INIS)

Borkowski, R.J.; Fragola, J.R.; Schurman, D.L.; Johnson, J.W.

1984-03-01

This report documents the procedure and final results of a feasibility study which examined the usefulness of nuclear plant maintenance work requests in the IPRDS as tools for understanding human error and its influence on component failure and repair. Developed in this study were (1) a set of criteria for judging the quality of a plant maintenance record set for studying human error; (2) a scheme for identifying human errors in the maintenance records; and (3) two taxonomies (engineering-based and psychology-based) for categorizing and coding human error-related events

Post-event human decision errors: operator action tree/time reliability correlation

International Nuclear Information System (INIS)

Hall, R.E.; Fragola, J.; Wreathall, J.

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations

Post-event human decision errors: operator action tree/time reliability correlation

Energy Technology Data Exchange (ETDEWEB)

Hall, R E; Fragola, J; Wreathall, J

1982-11-01

This report documents an interim framework for the quantification of the probability of errors of decision on the part of nuclear power plant operators after the initiation of an accident. The framework can easily be incorporated into an event tree/fault tree analysis. The method presented consists of a structure called the operator action tree and a time reliability correlation which assumes the time available for making a decision to be the dominating factor in situations requiring cognitive human response. This limited approach decreases the magnitude and complexity of the decision modeling task. Specifically, in the past, some human performance models have attempted prediction by trying to emulate sequences of human actions, or by identifying and modeling the information processing approach applicable to the task. The model developed here is directed at describing the statistical performance of a representative group of hypothetical individuals responding to generalized situations.

Human error: An essential problem of nuclear power plants

International Nuclear Information System (INIS)

Smidt, D.

1981-01-01

The author first defines the part played by man in the nuclear power plant and then deals in more detail with the structure of his valse behavior in tactical and strategic repect. The dicussion of tactical errors and their avoidance is follwed by a report on the actual state of plant technology and possible improvements. Subsequently a study of the strategic errors including the conclusion to be drawn until now (joint between plant and man, personal selection and education) is made. If the joints between man and machine are designed according and physiological strenghts and weaknesses of man are fully realized and taken into account human errors not be essential problem in nuclear power plant. (GL) [de

A methodology for analysing human errors of commission in accident scenarios for risk assessment

International Nuclear Information System (INIS)

Kim, J. H.; Jung, W. D.; Park, J. K

2003-01-01

As the concern on the impact of the operator's inappropriate interventions, so-called Errors Of Commissions(EOCs), on the plant safety has been raised, the interest in the identification and analysis of EOC events from the risk assessment perspective becomes increasing accordingly. To this purpose, we propose a new methodology for identifying and analysing human errors of commission that might be caused from the failures in situation assessment and decision making during accident progressions given an initiating event. The proposed methodology was applied to the accident scenarios of YGN 3 and 4 NPPs, which resulted in about 10 EOC situations that need careful attention

Data Analysis & Statistical Methods for Command File Errors

Science.gov (United States)

Meshkat, Leila; Waggoner, Bruce; Bryant, Larry

2014-01-01

This paper explains current work on modeling for managing the risk of command file errors. It is focused on analyzing actual data from a JPL spaceflight mission to build models for evaluating and predicting error rates as a function of several key variables. We constructed a rich dataset by considering the number of errors, the number of files radiated, including the number commands and blocks in each file, as well as subjective estimates of workload and operational novelty. We have assessed these data using different curve fitting and distribution fitting techniques, such as multiple regression analysis, and maximum likelihood estimation to see how much of the variability in the error rates can be explained with these. We have also used goodness of fit testing strategies and principal component analysis to further assess our data. Finally, we constructed a model of expected error rates based on the what these statistics bore out as critical drivers to the error rate. This model allows project management to evaluate the error rate against a theoretically expected rate as well as anticipate future error rates.

THERP and HEART integrated methodology for human error assessment

Science.gov (United States)

Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio

2015-11-01

THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead to patient radiological overexposures. The results allow for the identification of human errors that are necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so that it can be properly monitored and appropriately managed.

Proactive error analysis of ultrasound-guided axillary brachial plexus block performance.

LENUS (Irish Health Repository)

O'Sullivan, Owen

2012-07-13

Detailed description of the tasks anesthetists undertake during the performance of a complex procedure, such as ultrasound-guided peripheral nerve blockade, allows elements that are vulnerable to human error to be identified. We have applied 3 task analysis tools to one such procedure, namely, ultrasound-guided axillary brachial plexus blockade, with the intention that the results may form a basis to enhance training and performance of the procedure.

Study on Performance Shaping Factors (PSFs) Quantification Method in Human Reliability Analysis (HRA)

International Nuclear Information System (INIS)

Kim, Ar Ryum; Jang, Inseok Jang; Seong, Poong Hyun; Park, Jinkyun; Kim, Jong Hyun

2015-01-01

The purpose of HRA implementation is 1) to achieve the human factor engineering (HFE) design goal of providing operator interfaces that will minimize personnel errors and 2) to conduct an integrated activity to support probabilistic risk assessment (PRA). For these purposes, various HRA methods have been developed such as technique for human error rate prediction (THERP), simplified plant analysis risk human reliability assessment (SPAR-H), cognitive reliability and error analysis method (CREAM) and so on. In performing HRA, such conditions that influence human performances have been represented via several context factors called performance shaping factors (PSFs). PSFs are aspects of the human's individual characteristics, environment, organization, or task that specifically decrements or improves human performance, thus respectively increasing or decreasing the likelihood of human errors. Most HRA methods evaluate the weightings of PSFs by expert judgment and explicit guidance for evaluating the weighting is not provided. It has been widely known that the performance of the human operator is one of the critical factors to determine the safe operation of NPPs. HRA methods have been developed to identify the possibility and mechanism of human errors. In performing HRA methods, the effect of PSFs which may increase or decrease human error should be investigated. However, the effect of PSFs were estimated by expert judgment so far. Accordingly, in order to estimate the effect of PSFs objectively, the quantitative framework to estimate PSFs by using PSF profiles is introduced in this paper

The using of the control room automation against human errors

International Nuclear Information System (INIS)

Kautto, A.

1993-01-01

The control room automation has developed very strongly during the 80's in IVO (Imatran Voima Oy). The former work expanded strongly with building of the full scope training simulator to the Loviisa plant. The important milestones has been, for example the testing of the Critical Function Monitoring System, a concept developed by Combustion Eng. Inc., in Loviisa training simulator 1982, the replacing of the process and simulator computers in Loviisa 1989, and 1990 and the presenting the use of the computer based procedures in training of operators 1993. With developing of automation and procedures it is possible to minimize the probability of human error. However, it is not possible totally eliminate the risks caused by human errors. (orig.)

An analysis of errors of commission in the Nordic nuclear power plants based on plant operating experience

International Nuclear Information System (INIS)

Pyy, P.; Bento, J.P.; Flodin, Y.

2001-12-01

The report presents the methodology followed, the material used and conclusions drawn in a study of active human failures. First, the report discusses the concept of active human failures in the context of human errors. Then, a simplified methodology is presented applicable to analysis of operating experience and documenting all kinds of human failures. Also the material and analysis procedure used in the three parts of the study are discussed. Finally, some selected highlights of results are presented with common conclusions and recommendations. (au)

Findings from analysing and quantifying human error using current methods

International Nuclear Information System (INIS)

Dang, V.N.; Reer, B.

1999-01-01

In human reliability analysis (HRA), the scarcity of data means that, at best, judgement must be applied to transfer to the domain of the analysis what data are available for similar tasks. In particular for the quantification of tasks involving decisions, the analyst has to choose among quantification approaches that all depend to a significant degree on expert judgement. The use of expert judgement can be made more reliable by eliciting relative judgements rather than absolute judgements. These approaches, which are based on multiple criterion decision theory, focus on ranking the tasks to be analysed by difficulty. While these approaches remedy at least partially the poor performance of experts in the estimation of probabilities, they nevertheless require the calibration of the relative scale on which the actions are ranked in order to obtain the probabilities of interest. This paper presents some results from a comparison of some current HRA methods performed in the frame of a study of SLIM calibration options. The HRA quantification methods THERP, HEART, and INTENT were applied to derive calibration human error probabilities for two groups of operator actions. (author)

Formal Analysis of Soft Errors using Theorem Proving

Directory of Open Access Journals (Sweden)

Sofiène Tahar

2013-07-01

Full Text Available Modeling and analysis of soft errors in electronic circuits has traditionally been done using computer simulations. Computer simulations cannot guarantee correctness of analysis because they utilize approximate real number representations and pseudo random numbers in the analysis and thus are not well suited for analyzing safety-critical applications. In this paper, we present a higher-order logic theorem proving based method for modeling and analysis of soft errors in electronic circuits. Our developed infrastructure includes formalized continuous random variable pairs, their Cumulative Distribution Function (CDF properties and independent standard uniform and Gaussian random variables. We illustrate the usefulness of our approach by modeling and analyzing soft errors in commonly used dynamic random access memory sense amplifier circuits.

Top-down and bottom-up definitions of human failure events in human reliability analysis

International Nuclear Information System (INIS)

Boring, Ronald Laurids

2014-01-01

In the probabilistic risk assessments (PRAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approaches should arrive at the same set of HFEs. This question is crucial, however, as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PRAs tend to be top-down - defined as a subset of the PRA - whereas the HFEs used in petroleum quantitative risk assessments (QRAs) often tend to be bottom-up - derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications.

Republished error management: Descriptions of verbal communication errors between staff. An analysis of 84 root cause analysis-reports from Danish hospitals

DEFF Research Database (Denmark)

Rabøl, Louise Isager; Andersen, Mette Lehmann; Østergaard, Doris

2011-01-01

Introduction Poor teamwork and communication between healthcare staff are correlated to patient safety incidents. However, the organisational factors responsible for these issues are unexplored. Root cause analyses (RCA) use human factors thinking to analyse the systems behind severe patient safety...... (30%)), communication errors between junior and senior staff members (11 (25%)), hesitance in speaking up (10 (23%)) and communication errors during teamwork (8 (18%)). The kappa values were 0.44-0.78. Unproceduralized communication and information exchange via telephone, related to transfer between...... incidents. The RCARs rich descriptions of the incidents revealed the organisational factors and needs related to these errors....

Task analysis and computer aid development for human reliability analysis in nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Yoon, W. C.; Kim, H.; Park, H. S.; Choi, H. H.; Moon, J. M.; Heo, J. Y.; Ham, D. H.; Lee, K. K.; Han, B. T. [Korea Advanced Institute of Science and Technology, Taejeon (Korea)

2001-04-01

Importance of human reliability analysis (HRA) that predicts the error's occurrence possibility in a quantitative and qualitative manners is gradually increased by human errors' effects on the system's safety. HRA needs a task analysis as a virtue step, but extant task analysis techniques have the problem that a collection of information about the situation, which the human error occurs, depends entirely on HRA analyzers. The problem makes results of the task analysis inconsistent and unreliable. To complement such problem, KAERI developed the structural information analysis (SIA) that helps to analyze task's structure and situations systematically. In this study, the SIA method was evaluated by HRA experts, and a prototype computerized supporting system named CASIA (Computer Aid for SIA) was developed for the purpose of supporting to perform HRA using the SIA method. Additionally, through applying the SIA method to emergency operating procedures, we derived generic task types used in emergency and accumulated the analysis results in the database of the CASIA. The CASIA is expected to help HRA analyzers perform the analysis more easily and consistently. If more analyses will be performed and more data will be accumulated to the CASIA's database, HRA analyzers can share freely and spread smoothly his or her analysis experiences, and there by the quality of the HRA analysis will be improved. 35 refs., 38 figs., 25 tabs. (Author)

Assessing human error during collecting a hydrocarbon sample of ...

African Journals Online (AJOL)

This paper reports the assessment method of the hydrocarbon sample collection standard operation procedure (SOP) using THERP. The Performance Shaping Factors (PSF) from THERP analyzed and assessed the human errors during collecting a hydrocarbon sample of a petrochemical refinery plant. Twenty-two ...

Bringing organizational factors to the fore of human error management

International Nuclear Information System (INIS)

Embrey, D.

1991-01-01

Human performance problems account for more than half of all significant events at nuclear power plants, even when these did not necessarily lead to severe accidents. In dealing with the management of human error, both technical and organizational factors need to be taken into account. Most important, a long-term commitment from senior management is needed. (author)

Preventing marine accidents caused by technology-induced human error

OpenAIRE

Bielić, Toni; Hasanspahić, Nermin; Čulin, Jelena

2017-01-01

The objective of embedding technology on board ships, to improve safety, is not fully accomplished. The paper studies marine accidents caused by human error resulting from improper human-technology interaction. The aim of the paper is to propose measures to prevent reoccurrence of such accidents. This study analyses the marine accident reports issued by Marine Accidents Investigation Branch covering the period from 2012 to 2014. The factors that caused these accidents are examined and categor...

Tailoring a Human Reliability Analysis to Your Industry Needs

Science.gov (United States)

DeMott, D. L.

2016-01-01

Companies at risk of accidents caused by human error that result in catastrophic consequences include: airline industry mishaps, medical malpractice, medication mistakes, aerospace failures, major oil spills, transportation mishaps, power production failures and manufacturing facility incidents. Human Reliability Assessment (HRA) is used to analyze the inherent risk of human behavior or actions introducing errors into the operation of a system or process. These assessments can be used to identify where errors are most likely to arise and the potential risks involved if they do occur. Using the basic concepts of HRA, an evolving group of methodologies are used to meet various industry needs. Determining which methodology or combination of techniques will provide a quality human reliability assessment is a key element to developing effective strategies for understanding and dealing with risks caused by human errors. There are a number of concerns and difficulties in "tailoring" a Human Reliability Assessment (HRA) for different industries. Although a variety of HRA methodologies are available to analyze human error events, determining the most appropriate tools to provide the most useful results can depend on industry specific cultures and requirements. Methodology selection may be based on a variety of factors that include: 1) how people act and react in different industries, 2) expectations based on industry standards, 3) factors that influence how the human errors could occur such as tasks, tools, environment, workplace, support, training and procedure, 4) type and availability of data, 5) how the industry views risk & reliability, and 6) types of emergencies, contingencies and routine tasks. Other considerations for methodology selection should be based on what information is needed from the assessment. If the principal concern is determination of the primary risk factors contributing to the potential human error, a more detailed analysis method may be employed

Human errors and violations in computer and information security: the viewpoint of network administrators and security specialists.

Science.gov (United States)

Kraemer, Sara; Carayon, Pascale

2007-03-01

This paper describes human errors and violations of end users and network administration in computer and information security. This information is summarized in a conceptual framework for examining the human and organizational factors contributing to computer and information security. This framework includes human error taxonomies to describe the work conditions that contribute adversely to computer and information security, i.e. to security vulnerabilities and breaches. The issue of human error and violation in computer and information security was explored through a series of 16 interviews with network administrators and security specialists. The interviews were audio taped, transcribed, and analyzed by coding specific themes in a node structure. The result is an expanded framework that classifies types of human error and identifies specific human and organizational factors that contribute to computer and information security. Network administrators tended to view errors created by end users as more intentional than unintentional, while errors created by network administrators as more unintentional than intentional. Organizational factors, such as communication, security culture, policy, and organizational structure, were the most frequently cited factors associated with computer and information security.

Understanding Human Error in Naval Aviation Mishaps.

Science.gov (United States)

Miranda, Andrew T

2018-04-01

To better understand the external factors that influence the performance and decisions of aviators involved in Naval aviation mishaps. Mishaps in complex activities, ranging from aviation to nuclear power operations, are often the result of interactions between multiple components within an organization. The Naval aviation mishap database contains relevant information, both in quantitative statistics and qualitative reports, that permits analysis of such interactions to identify how the working atmosphere influences aviator performance and judgment. Results from 95 severe Naval aviation mishaps that occurred from 2011 through 2016 were analyzed using Bayes' theorem probability formula. Then a content analysis was performed on a subset of relevant mishap reports. Out of the 14 latent factors analyzed, the Bayes' application identified 6 that impacted specific aspects of aviator behavior during mishaps. Technological environment, misperceptions, and mental awareness impacted basic aviation skills. The remaining 3 factors were used to inform a content analysis of the contextual information within mishap reports. Teamwork failures were the result of plan continuation aggravated by diffused responsibility. Resource limitations and risk management deficiencies impacted judgments made by squadron commanders. The application of Bayes' theorem to historical mishap data revealed the role of latent factors within Naval aviation mishaps. Teamwork failures were seen to be considerably damaging to both aviator skill and judgment. Both the methods and findings have direct application for organizations interested in understanding the relationships between external factors and human error. It presents real-world evidence to promote effective safety decisions.

Comparison of methods for dependency determination between human failure events within human reliability analysis

International Nuclear Information System (INIS)

Cepis, M.

2007-01-01

The Human Reliability Analysis (HRA) is a highly subjective evaluation of human performance, which is an input for probabilistic safety assessment, which deals with many parameters of high uncertainty. The objective of this paper is to show that subjectivism can have a large impact on human reliability results and consequently on probabilistic safety assessment results and applications. The objective is to identify the key features, which may decrease of subjectivity of human reliability analysis. Human reliability methods are compared with focus on dependency comparison between Institute Jozef Stefan - Human Reliability Analysis (IJS-HRA) and Standardized Plant Analysis Risk Human Reliability Analysis (SPAR-H). Results show large differences in the calculated human error probabilities for the same events within the same probabilistic safety assessment, which are the consequence of subjectivity. The subjectivity can be reduced by development of more detailed guidelines for human reliability analysis with many practical examples for all steps of the process of evaluation of human performance. (author)

Comparison of Methods for Dependency Determination between Human Failure Events within Human Reliability Analysis

International Nuclear Information System (INIS)

Cepin, M.

2008-01-01

The human reliability analysis (HRA) is a highly subjective evaluation of human performance, which is an input for probabilistic safety assessment, which deals with many parameters of high uncertainty. The objective of this paper is to show that subjectivism can have a large impact on human reliability results and consequently on probabilistic safety assessment results and applications. The objective is to identify the key features, which may decrease subjectivity of human reliability analysis. Human reliability methods are compared with focus on dependency comparison between Institute Jozef Stefan human reliability analysis (IJS-HRA) and standardized plant analysis risk human reliability analysis (SPAR-H). Results show large differences in the calculated human error probabilities for the same events within the same probabilistic safety assessment, which are the consequence of subjectivity. The subjectivity can be reduced by development of more detailed guidelines for human reliability analysis with many practical examples for all steps of the process of evaluation of human performance

Standardizing the practice of human reliability analysis

International Nuclear Information System (INIS)

Hallbert, B.P.

1993-01-01

The practice of human reliability analysis (HRA) within the nuclear industry varies greatly in terms of posited mechanisms that shape human performance, methods of characterizing and analytically modeling human behavior, and the techniques that are employed to estimate the frequency with which human error occurs. This variation has been a source of contention among HRA practitioners regarding the validity of results obtained from different HRA methods. It has also resulted in attempts to develop standard methods and procedures for conducting HRAs. For many of the same reasons, the practice of HRA has not been standardized or has been standardized only to the extent that individual analysts have developed heuristics and consistent approaches in their practice of HRA. From the standpoint of consumers and regulators, this has resulted in a lack of clear acceptance criteria for the assumptions, modeling, and quantification of human errors in probabilistic risk assessments

Analysis of the interface tracking errors

International Nuclear Information System (INIS)

Cerne, G.; Tiselj, I.; Petelin, S.

2001-01-01

An important limitation of the interface-tracking algorithm is the grid density, which determines the space scale of the surface tracking. In this paper the analysis of the interface tracking errors, which occur in a dispersed flow, is performed for the VOF interface tracking method. A few simple two-fluid tests are proposed for the investigation of the interface tracking errors and their grid dependence. When the grid density becomes too coarse to follow the interface changes, the errors can be reduced either by using denser nodalization or by switching to the two-fluid model during the simulation. Both solutions are analyzed and compared on a simple vortex-flow test.(author)

Human error data collection as a precursor to the development of a human reliability assessment capability in air traffic management

International Nuclear Information System (INIS)

Kirwan, Barry; Gibson, W. Huw; Hickling, Brian

2008-01-01

Quantified risk and safety assessments are now required for safety cases for European air traffic management (ATM) services. Since ATM is highly human-dependent for its safety, this suggests a need for formal human reliability assessment (HRA), as carried out in other industries such as nuclear power. Since the fundamental aspect of HRA is human error data, in the form of human error probabilities (HEPs), it was decided to take a first step towards development of an ATM HRA approach by deriving some HEPs in an ATM context. This paper reports a study, which collected HEPs via analysing the results of a real-time simulation involving air traffic controllers (ATCOs) and pilots, with a focus on communication errors. This study did indeed derive HEPs that were found to be concordant with other known communication human error data. This is a first step, and shows promise for HRA in ATM, since HEPs have been derived which could be used in safety assessments, although these HEPs are for only one (albeit critical) aspect of ATCOs' tasks (communications). The paper discusses options and potential ways forward for the development of a full HRA capability in ATM

Techniques and applications of the human reliability analysis in nuclear facilities

International Nuclear Information System (INIS)

Pinto, Fausto C.

1995-01-01

The analysis and prediction of the man-machine interaction are the objectives of human reliability analysis. In this work is presented in a manner that could be used by experts in the field of Probabilistic Safety Assessment, considering primarily the aspects of human errors. The Technique of Human Error Rate Prediction (THERP) is used in large scale to obtain data on human error. Applications of this technique are presented, as well as aspects of the state-of-art and of research and development of this particular field of work, where the construction of a reliable data bank is considered essential. In this work is also developed an application of the THERP for the TRIGA Mark 1 IPR R-1 Reactor of the Centro de Desenvolvimento de Tecnologia Nuclear, Brazilian research institute of nuclear technology. The results indicate that some changes must be made in the emergency procedures of the reactor, in order to achieve a higher level of safety

Sample Size Bounding and Context Ranking as Approaches to the Human Error Quantification Problem

Energy Technology Data Exchange (ETDEWEB)

Reer, B

2004-03-01

The paper describes a technique denoted as Sub-Sample-Size Bounding (SSSB), which is useable for the statistical derivation of context-specific probabilities from data available in existing reports on operating experience. Applications to human reliability analysis (HRA) are emphasised in the presentation of this technique. Exemplified by a sample of 180 abnormal event sequences, the manner in which SSSB can provide viable input for the quantification of errors of commission (EOCs) are outlined. (author)

Sample Size Bounding and Context Ranking as Approaches to the Human Error Quantification Problem

International Nuclear Information System (INIS)

Reer, B.

2004-01-01

The paper describes a technique denoted as Sub-Sample-Size Bounding (SSSB), which is useable for the statistical derivation of context-specific probabilities from data available in existing reports on operating experience. Applications to human reliability analysis (HRA) are emphasised in the presentation of this technique. Exemplified by a sample of 180 abnormal event sequences, the manner in which SSSB can provide viable input for the quantification of errors of commission (EOCs) are outlined. (author)

Evaluation of Analysis by Cross-Validation, Part II: Diagnostic and Optimization of Analysis Error Covariance

Directory of Open Access Journals (Sweden)

Richard Ménard

2018-02-01

Full Text Available We present a general theory of estimation of analysis error covariances based on cross-validation as well as a geometric interpretation of the method. In particular, we use the variance of passive observation-minus-analysis residuals and show that the true analysis error variance can be estimated, without relying on the optimality assumption. This approach is used to obtain near optimal analyses that are then used to evaluate the air quality analysis error using several different methods at active and passive observation sites. We compare the estimates according to the method of Hollingsworth-Lönnberg, Desroziers et al., a new diagnostic we developed, and the perceived analysis error computed from the analysis scheme, to conclude that, as long as the analysis is near optimal, all estimates agree within a certain error margin.

Identification of failure sequences sensitive to human error

International Nuclear Information System (INIS)

1987-06-01

This report prepared by the participants of the technical committee meeting on ''Identification of Failure Sequences Sensitive to Human Error'' addresses the subjects discussed during the meeting and the conclusions reached by the committee. Chapter 1 reviews the INSAG recommendations and the main elements of the IAEA Programme in the area of human element. In Chapter 2 the role of human actions in nuclear power plants safety from insights of operational experience is reviewed. Chapter 3 is concerned with the relationship between probabilistic safety assessment and human performance associated with severe accident sequences. Chapter 4 addresses the role of simulators in view of training for accident conditions. Chapter 5 presents the conclusions and future trends. The seven papers presented by members of this technical committee are also included in this technical document. A separate abstract was prepared for each of these papers

A framework to assess diagnosis error probabilities in the advanced MCR

Energy Technology Data Exchange (ETDEWEB)

Kim, Ar Ryum; Seong, Poong Hyun [KAIST, Daejeon (Korea, Republic of); Kim, Jong Hyun [Chosun University, Gwangju (Korea, Republic of); Jang, Inseok; Park, Jinkyun [Korea Atomic Research Institute, Daejeon (Korea, Republic of)

2016-10-15

The Institute of Nuclear Power Operations (INPO)’s operating experience database revealed that about 48% of the total events in world NPPs for 2 years (2010-2011) happened due to human errors. The purposes of human reliability analysis (HRA) method are to evaluate the potential for, and mechanism of, human errors that may affect plant safety. Accordingly, various HRA methods have been developed such as technique for human error rate prediction (THERP), simplified plant analysis risk human reliability assessment (SPAR-H), cognitive reliability and error analysis method (CREAM) and so on. Many researchers have asserted that procedure, alarm, and display are critical factors to affect operators’ generic activities, especially for diagnosis activities. None of various HRA methods was explicitly designed to deal with digital systems. SCHEME (Soft Control Human error Evaluation MEthod) considers only for the probability of soft control execution error in the advanced MCR. The necessity of developing HRA methods in various conditions of NPPs has been raised. In this research, the framework to estimate diagnosis error probabilities in the advanced MCR was suggested. The assessment framework was suggested by three steps. The first step is to investigate diagnosis errors and calculate their probabilities. The second step is to quantitatively estimate PSFs’ weightings in the advanced MCR. The third step is to suggest the updated TRC model to assess the nominal diagnosis error probabilities. Additionally, the proposed framework was applied by using the full-scope simulation. Experiments conducted in domestic full-scope simulator and HAMMLAB were used as data-source. Total eighteen tasks were analyzed and twenty-three crews participated in.

Analysis of field errors in existing undulators

International Nuclear Information System (INIS)

Kincaid, B.M.