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

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...

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

International Nuclear Information System (INIS)

Lee, Yong Hee; Lee, Yong Hee

2011-01-01

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

A Preliminary Study on the Measures to Assess the Organizational Safety: The Cultural Impact on Human Error Potential

Energy Technology Data Exchange (ETDEWEB)

Lee, Yong Hee; Lee, Yong Hee [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2011-10-15

The Fukushima I nuclear accident following the Tohoku earthquake and tsunami on 11 March 2011 occurred after twelve years had passed since the JCO accident which was caused as a result of an error made by JCO employees. These accidents, along with the Chernobyl accident, associated with characteristic problems of various organizations caused severe social and economic disruptions and have had significant environmental and health impact. The cultural problems with human errors occur for various reasons, and different actions are needed to prevent different errors. Unfortunately, much of the research on organization and human error has shown widely various or different results which call for different approaches. In other words, we have to find more practical solutions from various researches for nuclear safety and lead a systematic approach to organizational deficiency causing human error. This paper reviews Hofstede's criteria, IAEA safety culture, safety areas of periodic safety review (PSR), teamwork and performance, and an evaluation of HANARO safety culture to verify the measures used to assess the organizational safety

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

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.

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

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.

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

Dependent Human Error Probability Assessment

International Nuclear Information System (INIS)

Simic, Z.; Mikulicic, V.; Vukovic, I.

2006-01-01

This paper presents an assessment of the dependence between dynamic operator actions modeled in a Nuclear Power Plant (NPP) PRA and estimate the associated impact on Core damage frequency (CDF). This assessment was done improve HEP dependencies implementation inside existing PRA. All of the dynamic operator actions modeled in the NPP PRA are included in this assessment. Determining the level of HEP dependence and the associated influence on CDF are the major steps of this assessment. A decision on how to apply the results, i.e., should permanent HEP model changes be made, is based on the resulting relative CDF increase. Some CDF increase was selected as a threshold based on the NPP base CDF value and acceptance guidelines from the Regulatory Guide 1.174. HEP dependence resulting in a CDF increase of > 5E-07 would be considered potential candidates for specific incorporation into the baseline model. The approach used to judge the level of dependence between operator actions is based on dependency level categories and conditional probabilities developed in the Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications NUREG/CR-1278. To simplify the process, NUREG/CR-1278 identifies five levels of dependence: ZD (zero dependence), LD (low dependence), MD (moderate dependence), HD (high dependence), and CD (complete dependence). NUREG/CR-1278 also identifies several qualitative factors that could be involved in determining the level of dependence. Based on the NUREG/CR-1278 information, Time, Function, and Spatial attributes were judged to be the most important considerations when determining the level of dependence between operator actions within an accident sequence. These attributes were used to develop qualitative criteria (rules) that were used to judge the level of dependence (CD, HD, MD, LD, ZD) between the operator actions. After the level of dependence between the various HEPs is judged, quantitative values associated with the

Evaluating the Performance Diagnostic Checklist-Human Services to Assess Incorrect Error-Correction Procedures by Preschool Paraprofessionals

Science.gov (United States)

Bowe, Melissa; Sellers, Tyra P.

2018-01-01

The Performance Diagnostic Checklist-Human Services (PDC-HS) has been used to assess variables contributing to undesirable staff performance. In this study, three preschool teachers completed the PDC-HS to identify the factors contributing to four paraprofessionals' inaccurate implementation of error-correction procedures during discrete trial…

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

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

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.

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

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....

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

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)

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 ...

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.

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

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.

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

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

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.)

The recovery factors analysis of the human errors for research reactors

International Nuclear Information System (INIS)

Farcasiu, M.; Nitoi, M.; Apostol, M.; Turcu, I.; Florescu, Ghe.

2006-01-01

The results of many Probabilistic Safety Assessment (PSA) studies show a very significant contribution of human errors to systems unavailability of the nuclear installations. The treatment of human interactions is considered one of the major limitations in the context of PSA. To identify those human actions that can have an effect on system reliability or availability applying the Human Reliability Analysis (HRA) is necessary. The recovery factors analysis of the human action is an important step in HRA. This paper presents how can be reduced the human errors probabilities (HEP) using those elements that have the capacity to recovery human error. The recovery factors modeling is marked to identify error likelihood situations or situations that conduct at development of the accident. This analysis is realized by THERP method. The necessary information was obtained from the operating experience of the research reactor TRIGA of the INR Pitesti. The required data were obtained from generic databases. (authors)

Human error risk management for engineering systems: a methodology for design, safety assessment, accident investigation and training

International Nuclear Information System (INIS)

Cacciabue, P.C.

2004-01-01

The objective of this paper is to tackle methodological issues associated with the inclusion of cognitive and dynamic considerations into Human Reliability methods. A methodology called Human Error Risk Management for Engineering Systems is presented that offers a 'roadmap' for selecting and consistently applying Human Factors approaches in different areas of application and contains also a 'body' of possible methods and techniques of its own. Two types of possible application are discussed to demonstrate practical applications of the methodology. Specific attention is dedicated to the issue of data collection and definition from specific field assessment

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

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

Analysis of Employee's Survey for Preventing Human-Errors

International Nuclear Information System (INIS)

Sung, Chanho; Kim, Younggab; Joung, Sanghoun

2013-01-01

Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses

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

A chance to avoid mistakes human error

International Nuclear Information System (INIS)

Amaro, Pablo; Obeso, Eduardo; Gomez, Ruben

2010-01-01

human factor contribution to the events 'The explanations of the error': The evolution of the human error concept and which are the causes that are behind him, are presented in this chapter. Several examples try to facilitate understanding. In the appendix II, we present a series of 'Cause Codes' used in the industry, trying to aid to the technicians when they are assessing and researching events. 'The battle against error': Its the main objective of the book. Present one after other, the tools that are managed in the nuclear industry in a practical way. What's, Who have to use it and When to use it, are described with sufficient detail so that anyone can assimilated the tool and, if is applicable, look for the implementation in his organization. (authors)

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

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

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.

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)

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

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.

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 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

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

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.)

Notes on human error analysis and prediction

International Nuclear Information System (INIS)

Rasmussen, J.

1978-11-01

The notes comprise an introductory discussion of the role of human error analysis and prediction in industrial risk analysis. Following this introduction, different classes of human errors and role in industrial systems are mentioned. Problems related to the prediction of human behaviour in reliability and safety analysis are formulated and ''criteria for analyzability'' which must be met by industrial systems so that a systematic analysis can be performed are suggested. The appendices contain illustrative case stories and a review of human error reports for the task of equipment calibration and testing as found in the US Licensee Event Reports. (author)

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...

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.)

Human Error Analysis by Fuzzy-Set

International Nuclear Information System (INIS)

Situmorang, Johnny

1996-01-01

In conventional HRA the probability of Error is treated as a single and exact value through constructing even tree, but in this moment the Fuzzy-Set Theory is used. Fuzzy set theory treat the probability of error as a plausibility which illustrate a linguistic variable. Most parameter or variable in human engineering been defined verbal good, fairly good, worst etc. Which describe a range of any value of probability. For example this analysis is quantified the human error in calibration task, and the probability of miscalibration is very low

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.

Estimation of the human error probabilities in the human reliability analysis

International Nuclear Information System (INIS)

Liu Haibin; He Xuhong; Tong Jiejuan; Shen Shifei

2006-01-01

Human error data is an important issue of human reliability analysis (HRA). Using of Bayesian parameter estimation, which can use multiple information, such as the historical data of NPP and expert judgment data to modify the human error data, could get the human error data reflecting the real situation of NPP more truly. This paper, using the numeric compute program developed by the authors, presents some typical examples to illustrate the process of the Bayesian parameter estimation in HRA and discusses the effect of different modification data on the Bayesian parameter estimation. (authors)

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

Human-simulation-based learning to prevent medication error: A systematic review.

Science.gov (United States)

Sarfati, Laura; Ranchon, Florence; Vantard, Nicolas; Schwiertz, Vérane; Larbre, Virginie; Parat, Stéphanie; Faudel, Amélie; Rioufol, Catherine

2018-01-31

In the past 2 decades, there has been an increasing interest in simulation-based learning programs to prevent medication error (ME). To improve knowledge, skills, and attitudes in prescribers, nurses, and pharmaceutical staff, these methods enable training without directly involving patients. However, best practices for simulation for healthcare providers are as yet undefined. By analysing the current state of experience in the field, the present review aims to assess whether human simulation in healthcare helps to reduce ME. A systematic review was conducted on Medline from 2000 to June 2015, associating the terms "Patient Simulation," "Medication Errors," and "Simulation Healthcare." Reports of technology-based simulation were excluded, to focus exclusively on human simulation in nontechnical skills learning. Twenty-one studies assessing simulation-based learning programs were selected, focusing on pharmacy, medicine or nursing students, or concerning programs aimed at reducing administration or preparation errors, managing crises, or learning communication skills for healthcare professionals. The studies varied in design, methodology, and assessment criteria. Few demonstrated that simulation was more effective than didactic learning in reducing ME. This review highlights a lack of long-term assessment and real-life extrapolation, with limited scenarios and participant samples. These various experiences, however, help in identifying the key elements required for an effective human simulation-based learning program for ME prevention: ie, scenario design, debriefing, and perception assessment. The performance of these programs depends on their ability to reflect reality and on professional guidance. Properly regulated simulation is a good way to train staff in events that happen only exceptionally, as well as in standard daily activities. By integrating human factors, simulation seems to be effective in preventing iatrogenic risk related to ME, if the program is

A comparative evaluation of five human reliability assessment techniques

International Nuclear Information System (INIS)

Kirwan, B.

1988-01-01

A field experiment was undertaken to evaluate the accuracy, usefulness, and resources requirements of five human reliability quantification techniques (Techniques for Human Error Rate Prediction (THERP); Paired Comparisons, Human Error Assessment and Reduction Technique (HEART), Success Liklihood Index Method (SLIM)-Multi Attribute Utility Decomposition (MAUD), and Absolute Probability Judgement). This was achieved by assessing technique predictions against a set of known human error probabilities, and by comparing their predictions on a set of five realistic Probabilisitc Risk Assessment (PRA) human error. On a combined measure of accuracy THERP and Absolute Probability Judgement performed best, whilst HEART showed indications of accuracy and was lower in resources usage than other techniques. HEART and THERP both appear to benefit from using trained assessors in order to obtain the best results. SLIM and Paired Comparisons require further research on achieving a robust calibration relationship between their scale values and absolute probabilities. (author)

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)

Analysis of Employee's Survey for Preventing Human-Errors

Energy Technology Data Exchange (ETDEWEB)

Sung, Chanho; Kim, Younggab; Joung, Sanghoun [KHNP Central Research Institute, Daejeon (Korea, Republic of)

2013-10-15

Human errors in nuclear power plant can cause large and small events or incidents. These events or incidents are one of main contributors of reactor trip and might threaten the safety of nuclear plants. To prevent human-errors, KHNP(nuclear power plants) introduced 'Human-error prevention techniques' and have applied the techniques to main parts such as plant operation, operation support, and maintenance and engineering. This paper proposes the methods to prevent and reduce human-errors in nuclear power plants through analyzing survey results which includes the utilization of the human-error prevention techniques and the employees' awareness of preventing human-errors. With regard to human-error prevention, this survey analysis presented the status of the human-error prevention techniques and the employees' awareness of preventing human-errors. Employees' understanding and utilization of the techniques was generally high and training level of employee and training effect on actual works were in good condition. Also, employees answered that the root causes of human-error were due to working environment including tight process, manpower shortage, and excessive mission rather than personal negligence or lack of personal knowledge. Consideration of working environment is certainly needed. At the present time, based on analyzing this survey, the best methods of preventing human-error are personal equipment, training/education substantiality, private mental health check before starting work, prohibit of multiple task performing, compliance with procedures, and enhancement of job site review. However, the most important and basic things for preventing human-error are interests of workers and organizational atmosphere such as communication between managers and workers, and communication between employees and bosses.

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)

Modeling human intention formation for human reliability assessment

International Nuclear Information System (INIS)

Woods, D.D.; Roth, E.M.; Pople, H. Jr.

1988-01-01

This paper describes a dynamic simulation capability for modeling how people form intentions to act in nuclear power plant emergency situations. This modeling tool, Cognitive Environment Simulation or CES, was developed based on techniques from artificial intelligence. It simulates the cognitive processes that determine situation assessment and intention formation. It can be used to investigate analytically what situations and factors lead to intention failures, what actions follow from intention failures (e.g. errors of omission, errors of commission, common mode errors), the ability to recover from errors or additional machine failures, and the effects of changes in the NPP person machine system. One application of the CES modeling environment is to enhance the measurement of the human contribution to risk in probabilistic risk assessment studies. (author)

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.

Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR): Data manual. Part 2: Human error probability (HEP) data; Volume 5, Revision 4

Energy Technology Data Exchange (ETDEWEB)

Reece, W.J.; Gilbert, B.G.; Richards, R.E. [EG and G Idaho, Inc., Idaho Falls, ID (United States)

1994-09-01

This data manual contains a hard copy of the information in the Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR) Version 3.5 database, which is sponsored by the US Nuclear Regulatory Commission. NUCLARR was designed as a tool for risk analysis. Many of the nuclear reactors in the US and several outside the US are represented in the NUCLARR database. NUCLARR includes both human error probability estimates for workers at the plants and hardware failure data for nuclear reactor equipment. Aggregations of these data yield valuable reliability estimates for probabilistic risk assessments and human reliability analyses. The data manual is organized to permit manual searches of the information if the computerized version is not available. Originally, the manual was published in three parts. In this revision the introductory material located in the original Part 1 has been incorporated into the text of Parts 2 and 3. The user can now find introductory material either in the original Part 1, or in Parts 2 and 3 as revised. Part 2 contains the human error probability data, and Part 3, the hardware component reliability data.

Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR): Data manual. Part 2: Human error probability (HEP) data; Volume 5, Revision 4

International Nuclear Information System (INIS)

Reece, W.J.; Gilbert, B.G.; Richards, R.E.

1994-09-01

This data manual contains a hard copy of the information in the Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR) Version 3.5 database, which is sponsored by the US Nuclear Regulatory Commission. NUCLARR was designed as a tool for risk analysis. Many of the nuclear reactors in the US and several outside the US are represented in the NUCLARR database. NUCLARR includes both human error probability estimates for workers at the plants and hardware failure data for nuclear reactor equipment. Aggregations of these data yield valuable reliability estimates for probabilistic risk assessments and human reliability analyses. The data manual is organized to permit manual searches of the information if the computerized version is not available. Originally, the manual was published in three parts. In this revision the introductory material located in the original Part 1 has been incorporated into the text of Parts 2 and 3. The user can now find introductory material either in the original Part 1, or in Parts 2 and 3 as revised. Part 2 contains the human error probability data, and Part 3, the hardware component reliability data

Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR): Data manual, Part 2: Human Error Probability (HEP) Data. Volume 5, Revision 4

International Nuclear Information System (INIS)

Reece, W.J.; Gilbert, B.G.; Richards, R.E.

1994-09-01

This data manual contains a hard copy of the information in the Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR) Version 3.5 database, which is sponsored by the US Nuclear Regulatory Commission. NUCLARR was designed as a tool for risk analysis. Many of the nuclear reactors in the US and several outside the US are represented in the NUCLARR database. NUCLARR includes both human error probability estimates for workers at the plants and hardware failure data for nuclear reactor equipment. Aggregations of these data yield valuable reliability estimates for probabilistic risk assessments and human reliability analyses. The data manual is organized to permit manual searches of the information if the computerized version is not available. Originally, the manual was published in three parts. In this revision the introductory material located in the original Part 1 has been incorporated into the text of Parts 2 and 3. The user can now find introductory material either in the original Part 1, or in Parts 2 and 3 as revised. Part 2 contains the human error probability data, and Part 3, the hardware component reliability data

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)

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

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

An advanced human reliability analysis methodology: analysis of cognitive errors focused on

International Nuclear Information System (INIS)

Kim, J. H.; Jeong, W. D.

2001-01-01

The conventional Human Reliability Analysis (HRA) methods such as THERP/ASEP, HCR and SLIM has been criticised for their deficiency in analysing cognitive errors which occurs during operator's decision making process. In order to supplement the limitation of the conventional methods, an advanced HRA method, what is called the 2 nd generation HRA method, including both qualitative analysis and quantitative assessment of cognitive errors has been being developed based on the state-of-the-art theory of cognitive systems engineering and error psychology. The method was developed on the basis of human decision-making model and the relation between the cognitive function and the performance influencing factors. The application of the proposed method to two emergency operation tasks is presented

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...

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

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

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)

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

Human reliability assessment and probabilistic risk assessment

International Nuclear Information System (INIS)

Embrey, D.E.; Lucas, D.A.

1989-01-01

Human reliability assessment (HRA) is used within Probabilistic Risk Assessment (PRA) to identify the human errors (both omission and commission) which have a significant effect on the overall safety of the system and to quantify the probability of their occurrence. There exist a variey of HRA techniques and the selection of an appropriate one is often difficult. This paper reviews a number of available HRA techniques and discusses their strengths and weaknesses. The techniques reviewed include: decompositional methods, time-reliability curves and systematic expert judgement techniques. (orig.)

SHEAN (Simplified Human Error Analysis code) and automated THERP

International Nuclear Information System (INIS)

Wilson, J.R.

1993-01-01

One of the most widely used human error analysis tools is THERP (Technique for Human Error Rate Prediction). Unfortunately, this tool has disadvantages. The Nuclear Regulatory Commission, realizing these drawbacks, commissioned Dr. Swain, the author of THERP, to create a simpler, more consistent tool for deriving human error rates. That effort produced the Accident Sequence Evaluation Program Human Reliability Analysis Procedure (ASEP), which is more conservative than THERP, but a valuable screening tool. ASEP involves answering simple questions about the scenario in question, and then looking up the appropriate human error rate in the indicated table (THERP also uses look-up tables, but four times as many). The advantages of ASEP are that human factors expertise is not required, and the training to use the method is minimal. Although not originally envisioned by Dr. Swain, the ASEP approach actually begs to be computerized. That WINCO did, calling the code SHEAN, for Simplified Human Error ANalysis. The code was done in TURBO Basic for IBM or IBM-compatible MS-DOS, for fast execution. WINCO is now in the process of comparing this code against THERP for various scenarios. This report provides a discussion of SHEAN

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

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

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

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

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.

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.)

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.

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

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.

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

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.

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)

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)

Introduction to precision machine design and error assessment

CERN Document Server

Mekid, Samir

2008-01-01

While ultra-precision machines are now achieving sub-nanometer accuracy, unique challenges continue to arise due to their tight specifications. Written to meet the growing needs of mechanical engineers and other professionals to understand these specialized design process issues, Introduction to Precision Machine Design and Error Assessment places a particular focus on the errors associated with precision design, machine diagnostics, error modeling, and error compensation. Error Assessment and ControlThe book begins with a brief overview of precision engineering and applications before introdu

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)

Beyond human error taxonomies in assessment of risk in sociotechnical systems: a new paradigm with the EAST 'broken-links' approach.

Science.gov (United States)

Stanton, Neville A; Harvey, Catherine

2017-02-01

Risk assessments in Sociotechnical Systems (STS) tend to be based on error taxonomies, yet the term 'human error' does not sit easily with STS theories and concepts. A new break-link approach was proposed as an alternative risk assessment paradigm to reveal the effect of information communication failures between agents and tasks on the entire STS. A case study of the training of a Royal Navy crew detecting a low flying Hawk (simulating a sea-skimming missile) is presented using EAST to model the Hawk-Frigate STS in terms of social, information and task networks. By breaking 19 social links and 12 task links, 137 potential risks were identified. Discoveries included revealing the effect of risk moving around the system; reducing the risks to the Hawk increased the risks to the Frigate. Future research should examine the effects of compounded information communication failures on STS performance. Practitioner Summary: The paper presents a step-by-step walk-through of EAST to show how it can be used for risk assessment in sociotechnical systems. The 'broken-links' method takes a systemic, rather than taxonomic, approach to identify information communication failures in social and task networks.

Human reliability assessment in context

International Nuclear Information System (INIS)

Hollnagel, Erik

2005-01-01

Human Reliability Assessment (HRA) is conducted on the unspoken premise that 'human error' is a meaningful concept and that it can be associated with individual actions. The basis for this assumption it found in the origin of HRA, as a necessary extension of PSA to account for the impact of failures emanating from human actions. Although it was natural to model HRA on PSA, a large number of studies have shown that the premises are wrong, specifically that human and technological functions cannot be decomposed in the same manner. The general experience from accident studies also indicates that action failures are a function of the context, and that it is the variability of the context rather than the 'human error probability' that is the much sought for signal. Accepting this will have significant consequences for the way in which HRA, and ultimately also PSA, should be pursued

A human error taxonomy for analysing healthcare incident reports: assessing reporting culture and its effects on safety perfomance

DEFF Research Database (Denmark)

Itoh, Kenji; Omata, N.; Andersen, Henning Boje

2009-01-01

The present paper reports on a human error taxonomy system developed for healthcare risk management and on its application to evaluating safety performance and reporting culture. The taxonomy comprises dimensions for classifying errors, for performance-shaping factors, and for the maturity...

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.

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

#2 - An Empirical Assessment of Exposure Measurement Error ...

Science.gov (United States)

Background• Differing degrees of exposure error acrosspollutants• Previous focus on quantifying and accounting forexposure error in single-pollutant models• Examine exposure errors for multiple pollutantsand provide insights on the potential for bias andattenuation of effect estimates in single and bipollutantepidemiological models The National Exposure Research Laboratory (NERL) Human Exposure and Atmospheric Sciences Division (HEASD) conducts research in support of EPA mission to protect human health and the environment. HEASD research program supports Goal 1 (Clean Air) and Goal 4 (Healthy People) of EPA strategic plan. More specifically, our division conducts research to characterize the movement of pollutants from the source to contact with humans. Our multidisciplinary research program produces Methods, Measurements, and Models to identify relationships between and characterize processes that link source emissions, environmental concentrations, human exposures, and target-tissue dose. The impact of these tools is improved regulatory programs and policies for EPA.

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

Wind power error estimation in resource assessments.

Directory of Open Access Journals (Sweden)

Osvaldo Rodríguez

Full Text Available Estimating the power output is one of the elements that determine the techno-economic feasibility of a renewable project. At present, there is a need to develop reliable methods that achieve this goal, thereby contributing to wind power penetration. In this study, we propose a method for wind power error estimation based on the wind speed measurement error, probability density function, and wind turbine power curves. This method uses the actual wind speed data without prior statistical treatment based on 28 wind turbine power curves, which were fitted by Lagrange's method, to calculate the estimate wind power output and the corresponding error propagation. We found that wind speed percentage errors of 10% were propagated into the power output estimates, thereby yielding an error of 5%. The proposed error propagation complements the traditional power resource assessments. The wind power estimation error also allows us to estimate intervals for the power production leveled cost or the investment time return. The implementation of this method increases the reliability of techno-economic resource assessment studies.

Wind power error estimation in resource assessments.

Science.gov (United States)

Rodríguez, Osvaldo; Del Río, Jesús A; Jaramillo, Oscar A; Martínez, Manuel

2015-01-01

Estimating the power output is one of the elements that determine the techno-economic feasibility of a renewable project. At present, there is a need to develop reliable methods that achieve this goal, thereby contributing to wind power penetration. In this study, we propose a method for wind power error estimation based on the wind speed measurement error, probability density function, and wind turbine power curves. This method uses the actual wind speed data without prior statistical treatment based on 28 wind turbine power curves, which were fitted by Lagrange's method, to calculate the estimate wind power output and the corresponding error propagation. We found that wind speed percentage errors of 10% were propagated into the power output estimates, thereby yielding an error of 5%. The proposed error propagation complements the traditional power resource assessments. The wind power estimation error also allows us to estimate intervals for the power production leveled cost or the investment time return. The implementation of this method increases the reliability of techno-economic resource assessment studies.

Psychological scaling of expert estimates of human error probabilities: application to nuclear power plant operation

International Nuclear Information System (INIS)

Comer, K.; Gaddy, C.D.; Seaver, D.A.; Stillwell, W.G.

1985-01-01

The US Nuclear Regulatory Commission and Sandia National Laboratories sponsored a project to evaluate psychological scaling techniques for use in generating estimates of human error probabilities. The project evaluated two techniques: direct numerical estimation and paired comparisons. Expert estimates were found to be consistent across and within judges. Convergent validity was good, in comparison to estimates in a handbook of human reliability. Predictive validity could not be established because of the lack of actual relative frequencies of error (which will be a difficulty inherent in validation of any procedure used to estimate HEPs). Application of expert estimates in probabilistic risk assessment and in human factors is discussed

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

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)

AGAPE-ET for human error analysis of emergency tasks and its application

International Nuclear Information System (INIS)

Kim, J. H.; Jeong, W. D.

2002-01-01

The paper presents a proceduralised human reliability analysis (HRA) methodology, AGAPE-ET (A Guidance And Procedure for Human Error Analysis for Emergency Tasks), covering both qualitative error analysis and quantification of human error probability (HEP) of emergency tasks in nuclear power plants. The AGAPE-ET method 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 the performance influencing factors (PIFs) on the cognitive function. Then, error analysis items have been determined from the identified error causes or error-likely situations and a human error analysis procedure based on the error analysis items is organised to help the analysts cue or guide overall human error analysis. 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 paper also presents the application of AGAPE-ET to 31 nuclear emergency tasks and its results

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

Operational human performance reliability assessment (OHPRA)

International Nuclear Information System (INIS)

Haas, P.M.; Swanson, P.J.; Connelly, E.M.

1993-01-01

Operational Human Performance Reliability Assessment (OHPRA) is an approach for assessing human performance that is being developed in response to demands from modern process industries for practical and effective tools to assess and improve human performance, and therefore overall system performance and safety. The single most distinguishing feature of the approach is that is defines human performance in open-quotes operationalclose quotes terms. OHPRA is focused not on generation of human error probabilities, but on practical analysis of human performance to aid management in (1) identifying open-quotes fixableclose quotes problems and (2) providing input on the importance and nature of potential improvements. Development of the model in progress uses a unique approach for eliciting expert strategies for assessing performance. A PC-based model incorporating this expertise is planned. A preliminary version of the approach has already been used successfully to identify practical human performance problems in reactor and chemical process plant operations

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....

The human error rate assessment and optimizing system HEROS - a new procedure for evaluating and optimizing the man-machine interface in PSA

International Nuclear Information System (INIS)

Richei, A.; Hauptmanns, U.; Unger, H.

2001-01-01

A new procedure allowing the probabilistic evaluation and optimization of the man-machine system is presented. This procedure and the resulting expert system HEROS, which is an acronym for Human Error Rate Assessment and Optimizing System, is based on the fuzzy set theory. Most of the well-known procedures employed for the probabilistic evaluation of human factors involve the use of vague linguistic statements on performance shaping factors to select and to modify basic human error probabilities from the associated databases. This implies a large portion of subjectivity. Vague statements are expressed here in terms of fuzzy numbers or intervals which allow mathematical operations to be performed on them. A model of the man-machine system is the basis of the procedure. A fuzzy rule-based expert system was derived from ergonomic and psychological studies. Hence, it does not rely on a database, whose transferability to situations different from its origin is questionable. In this way, subjective elements are eliminated to a large extent. HEROS facilitates the importance analysis for the evaluation of human factors, which is necessary for optimizing the man-machine system. HEROS is applied to the analysis of a simple diagnosis of task of the operating personnel in a nuclear power plant

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)

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

Knowledge-base for the new human reliability analysis method, A Technique for Human Error Analysis (ATHEANA)

International Nuclear Information System (INIS)

Cooper, S.E.; Wreathall, J.; Thompson, C.M., Drouin, M.; Bley, D.C.

1996-01-01

This paper describes the knowledge base for the application of the new human reliability analysis (HRA) method, a ''A Technique for Human Error Analysis'' (ATHEANA). Since application of ATHEANA requires the identification of previously unmodeled human failure events, especially errors of commission, and associated error-forcing contexts (i.e., combinations of plant conditions and performance shaping factors), this knowledge base is an essential aid for the HRA analyst

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,

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.

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

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.

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

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

A stochastic dynamic model for human error analysis in nuclear power plants

Science.gov (United States)

Delgado-Loperena, Dharma

Nuclear disasters like Three Mile Island and Chernobyl indicate that human performance is a critical safety issue, sending a clear message about the need to include environmental press and competence aspects in research. This investigation was undertaken to serve as a roadmap for studying human behavior through the formulation of a general solution equation. The theoretical model integrates models from two heretofore-disassociated disciplines (behavior specialists and technical specialists), that historically have independently studied the nature of error and human behavior; including concepts derived from fractal and chaos theory; and suggests re-evaluation of base theory regarding human error. The results of this research were based on comprehensive analysis of patterns of error, with the omnipresent underlying structure of chaotic systems. The study of patterns lead to a dynamic formulation, serving for any other formula used to study human error consequences. The search for literature regarding error yielded insight for the need to include concepts rooted in chaos theory and strange attractors---heretofore unconsidered by mainstream researchers who investigated human error in nuclear power plants or those who employed the ecological model in their work. The study of patterns obtained from the rupture of a steam generator tube (SGTR) event simulation, provided a direct application to aspects of control room operations in nuclear power plant operations. In doing so, the conceptual foundation based in the understanding of the patterns of human error analysis can be gleaned, resulting in reduced and prevent undesirable events.

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)

Expert estimation of human error probabilities in nuclear power plant operations: a review of probability assessment and scaling

International Nuclear Information System (INIS)

Stillwell, W.G.; Seaver, D.A.; Schwartz, J.P.

1982-05-01

This report reviews probability assessment and psychological scaling techniques that could be used to estimate human error probabilities (HEPs) in nuclear power plant operations. The techniques rely on expert opinion and can be used to estimate HEPs where data do not exist or are inadequate. These techniques have been used in various other contexts and have been shown to produce reasonably accurate probabilities. Some problems do exist, and limitations are discussed. Additional topics covered include methods for combining estimates from multiple experts, the effects of training on probability estimates, and some ideas on structuring the relationship between performance shaping factors and HEPs. Preliminary recommendations are provided along with cautions regarding the costs of implementing the recommendations. Additional research is required before definitive recommendations can be made

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)

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

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

Dependence assessment in human reliability analysis based on D numbers and AHP

International Nuclear Information System (INIS)

Zhou, Xinyi; Deng, Xinyang; Deng, Yong; Mahadevan, Sankaran

2017-01-01

Highlights: • D numbers and AHP are combined to implement dependence assessment in HRA. • A new tool, called D numbers, is used to deal with the uncertainty in HRA. • The proposed method can well address the fuzziness and subjectivity in linguistic assessment. • The proposed method is well applicable in dependence assessment which inherently has a linguistic assessment process. - Abstract: Since human errors always cause heavy loss especially in nuclear engineering, human reliability analysis (HRA) has attracted more and more attention. Dependence assessment plays a vital role in HRA, measuring the dependence degree of human errors. Many researches have been done while still have improvement space. In this paper, a dependence assessment model based on D numbers and analytic hierarchy process (AHP) is proposed. Firstly, identify the factors used to measure the dependence level of two human operations. Besides, in terms of the suggested dependence level, determine and quantify the anchor points for each factor. Secondly, D numbers and AHP are adopted in model. Experts evaluate the dependence level of human operations for each factor. Then, the evaluation results are presented as D numbers and fused by D number’s combination rule that can obtain the dependence probability of human operations for each factor. The weights of factors can be determined by AHP. Thirdly, based on the dependence probability for each factor and its corresponding weight, the dependence probability of two human operations and its confidence can be obtained. The proposed method can well address the fuzziness and subjectivity in linguistic assessment. The proposed method is well applicable to assess the dependence degree of human errors in HRA which inherently has a linguistic assessment process.

Dependence assessment in human reliability analysis based on D numbers and AHP

Energy Technology Data Exchange (ETDEWEB)

Zhou, Xinyi; Deng, Xinyang [School of Computer and Information Science, Southwest University, Chongqing 400715 (China); Deng, Yong, E-mail: ydeng@swu.edu.cn [School of Computer and Information Science, Southwest University, Chongqing 400715 (China); Institute of Fundamental and Frontier Sciences, University of Electronic Science and Technology of China, Chengdu, Sichuan 610054 (China); Mahadevan, Sankaran [School of Engineering, Vanderbilt University, Nashville, TN 37235 (United States)

2017-03-15

Highlights: • D numbers and AHP are combined to implement dependence assessment in HRA. • A new tool, called D numbers, is used to deal with the uncertainty in HRA. • The proposed method can well address the fuzziness and subjectivity in linguistic assessment. • The proposed method is well applicable in dependence assessment which inherently has a linguistic assessment process. - Abstract: Since human errors always cause heavy loss especially in nuclear engineering, human reliability analysis (HRA) has attracted more and more attention. Dependence assessment plays a vital role in HRA, measuring the dependence degree of human errors. Many researches have been done while still have improvement space. In this paper, a dependence assessment model based on D numbers and analytic hierarchy process (AHP) is proposed. Firstly, identify the factors used to measure the dependence level of two human operations. Besides, in terms of the suggested dependence level, determine and quantify the anchor points for each factor. Secondly, D numbers and AHP are adopted in model. Experts evaluate the dependence level of human operations for each factor. Then, the evaluation results are presented as D numbers and fused by D number’s combination rule that can obtain the dependence probability of human operations for each factor. The weights of factors can be determined by AHP. Thirdly, based on the dependence probability for each factor and its corresponding weight, the dependence probability of two human operations and its confidence can be obtained. The proposed method can well address the fuzziness and subjectivity in linguistic assessment. The proposed method is well applicable to assess the dependence degree of human errors in HRA which inherently has a linguistic assessment process.

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 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

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)

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

KAUST Repository

Shwartz, L.

2010-12-01

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% of interruptions were caused by human error. We focus on Change Management, the process with the largest risk of human error, and identify the main instances of human errors as the 4 Wrongs: request, time, configuration item, and command. Analysis of change records revealed that the humanerror prevention by partial automation is highly relevant. We propose the HEP Framework, a framework for execution of IT Service Delivery operations that reduces human error by addressing the 4 Wrongs using content integration, contextualization of operation patterns, partial automation of command execution, and controlled access to resources.

HUMAN RELIABILITY ANALYSIS DENGAN PENDEKATAN COGNITIVE RELIABILITY AND ERROR ANALYSIS METHOD (CREAM

Directory of Open Access Journals (Sweden)

Zahirah Alifia Maulida

2015-01-01

Full Text Available Kecelakaan kerja pada bidang grinding dan welding menempati urutan tertinggi selama lima tahun terakhir di PT. X. Kecelakaan ini disebabkan oleh human error. Human error terjadi karena pengaruh lingkungan kerja fisik dan non fisik.Penelitian kali menggunakan skenario untuk memprediksi serta mengurangi kemungkinan terjadinya error pada manusia dengan pendekatan CREAM (Cognitive Reliability and Error Analysis Method. CREAM adalah salah satu metode human reliability analysis yang berfungsi untuk mendapatkan nilai Cognitive Failure Probability (CFP yang dapat dilakukan dengan dua cara yaitu basic method dan extended method. Pada basic method hanya akan didapatkan nilai failure probabailty secara umum, sedangkan untuk extended method akan didapatkan CFP untuk setiap task. Hasil penelitian menunjukkan faktor- faktor yang mempengaruhi timbulnya error pada pekerjaan grinding dan welding adalah kecukupan organisasi, kecukupan dari Man Machine Interface (MMI & dukungan operasional, ketersediaan prosedur/ perencanaan, serta kecukupan pelatihan dan pengalaman. Aspek kognitif pada pekerjaan grinding yang memiliki nilai error paling tinggi adalah planning dengan nilai CFP 0.3 dan pada pekerjaan welding yaitu aspek kognitif execution dengan nilai CFP 0.18. Sebagai upaya untuk mengurangi nilai error kognitif pada pekerjaan grinding dan welding rekomendasi yang diberikan adalah memberikan training secara rutin, work instrucstion yang lebih rinci dan memberikan sosialisasi alat. Kata kunci: CREAM (cognitive reliability and error analysis method, HRA (human reliability analysis, cognitive error Abstract The accidents in grinding and welding sectors were the highest cases over the last five years in PT. X and it caused by human error. Human error occurs due to the influence of working environment both physically and non-physically. This study will implement an approaching scenario called CREAM (Cognitive Reliability and Error Analysis Method. CREAM is one of human

The Theory and Assessment of Spatial Straightness Error Matched New Generation GPS

International Nuclear Information System (INIS)

Zhang, X B; Sheng, X L; Jiang, X Q; Li, Z

2006-01-01

In order to assess spatial straightness error matched new generation Dimensional Geometrical Product Specification and Verification (GPS), the theory of spatial straightness error assessing is proposed and its advantages are analyzed based on metrology and statistics in this paper. Then, the assessing parameter system is proposed and it is testified in real application comparing to assessment result of the geometric tolerance theory. Statistical parameters of this assessing system post the different characteristics of spatial straightness error, and can reveal the impact of spatial straightness error on the accessory function more roundly to complement the single assessing parameter of geometrical tolerance for straightness error. The statistical spatial straightness tolerance and statistical spatial straightness error proposed in this paper is possible to be applied in evaluation of other error of form, orientation, location and run-out

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

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 reliability in probabilistic safety assessments

International Nuclear Information System (INIS)

Nunez Mendez, J.

1989-01-01

Nowadays a growing interest in medioambiental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processess and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects. (This relevance has been demostrated in the accidents happenned). However in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a guide to carry out a Human Reliability Analysis and c) a selected overwiev of the techniques and methodologies currently applied in this area. (Author)

The assessment system based on virtual decommissioning environments to reduce abnormal hazards from human errors for decommissioning of nuclear facilities

Energy Technology Data Exchange (ETDEWEB)

Jeong, Kwan Seong; Moon, Jei Kwon; Choi, Byung Seon; Hyun, Dong jun; Lee, Jong Hwan; Kim, Ik June; Kang, Shin Young [KAERI, Daejeon (Korea, Republic of)

2016-05-15

Decommissioning of nuclear facilities has to be accomplished by assuring the safety of workers. So, it is necessary that before decommissioning, the exposure dose to workers has to be analyzed and assessed under the principle of ALARA (as low as reasonably achievable). Furthermore, to improve the proficiency of decommissioning environments, method and system need to be developed. To establish the plan of exposure dose to workers during decommissioning of nuclear facilities before decommissioning activities, it is necessary that assessment system is developed. This system has been successfully developed so that exposure dose to workers could be real-time measured and assessed in virtual decommissioning environments. It can be concluded that this system could be protected from accidents and enable workers to improve his familiarization about working environments. It is expected that this system can reduce human errors because workers are able to improve the proficiency of hazardous working environments due to virtual training like real decommissioning situations.

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

Human reliability assessment on the basis of operating experience

International Nuclear Information System (INIS)

Straeter, O.

1997-01-01

For development of methodology, available models for qualitative assessment of human errors (e.g. by Swain, Hacker, Rasmussen) and a variety of known systematic approaches for quantitiative assessment of inadequate human action (e.g. THERP, ASEP, HCR, SLIM) were taken as a basis to establish a job specification, which in turn was used for developing a method for acquisition, characterisation and evaluation of errors. This method encompasses the two processes of event analysis and event evaluation: The first step comprises analysis of events by analysis of information describing the conditions and scenarios of relevance to the inadequate human action examined. In addition to the description of process sequences, information is taken into account on possible conditions that may bring about failure. As an assessment of human reliability requires manifold approaches for evaluation, a connectionistic procedure was developed for evaluation of the compilation of events based on a debate about various approaches from the domain of artificial intelligence (AI). This procedure yields both qualitative and quantitative information through a homogenous approach. (orig./GL) [de

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 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.

Potential Errors and Test Assessment in Software Product Line Engineering

Directory of Open Access Journals (Sweden)

Hartmut Lackner

2015-04-01

Full Text Available Software product lines (SPL are a method for the development of variant-rich software systems. Compared to non-variable systems, testing SPLs is extensive due to an increasingly amount of possible products. Different approaches exist for testing SPLs, but there is less research for assessing the quality of these tests by means of error detection capability. Such test assessment is based on error injection into correct version of the system under test. However to our knowledge, potential errors in SPL engineering have never been systematically identified before. This article presents an overview over existing paradigms for specifying software product lines and the errors that can occur during the respective specification processes. For assessment of test quality, we leverage mutation testing techniques to SPL engineering and implement the identified errors as mutation operators. This allows us to run existing tests against defective products for the purpose of test assessment. From the results, we draw conclusions about the error-proneness of the surveyed SPL design paradigms and how quality of SPL tests can be improved.

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

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)

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

Analysis of measured data of human body based on error correcting frequency

Science.gov (United States)

Jin, Aiyan; Peipei, Gao; Shang, Xiaomei

2014-04-01

Anthropometry is to measure all parts of human body surface, and the measured data is the basis of analysis and study of the human body, establishment and modification of garment size and formulation and implementation of online clothing store. In this paper, several groups of the measured data are gained, and analysis of data error is gotten by analyzing the error frequency and using analysis of variance method in mathematical statistics method. Determination of the measured data accuracy and the difficulty of measured parts of human body, further studies of the causes of data errors, and summarization of the key points to minimize errors possibly are also mentioned in the paper. This paper analyses the measured data based on error frequency, and in a way , it provides certain reference elements to promote the garment industry development.

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

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.

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)

Human Reliability in Probabilistic Safety Assessments

International Nuclear Information System (INIS)

Nunez Mendez, J.

1989-01-01

Nowadays a growing interest in environmental aspects is detected in our country. It implies an assessment of the risk involved in the industrial processes and installations in order to determine if those are into the acceptable limits. In these safety assessments, among which PSA (Probabilistic Safety Assessments), can be pointed out the role played by the human being in the system is one of the more relevant subjects (This relevance has been demonstrated in the accidents happened) . However, in Spain there aren't manuals specifically dedicated to asses the human contribution to risk in the frame of PSAs. This report aims to improve this situation providing: a) a theoretical background to help the reader in the understanding of the nature of the human error, b) a quid to carry out a Human Reliability Analysis and c) a selected overview of the techniques and methodologies currently applied in this area. (Author) 20 refs

Human performance assessment: methods and measures

International Nuclear Information System (INIS)

Andresen, Gisle; Droeivoldsmo, Asgeir

2000-10-01

The Human Error Analysis Project (HEAP) was initiated in 1994. The aim of the project was to acquire insights on how and why cognitive errors occur when operators are engaged in problem solving in advanced integrated control rooms. Since human error had not been studied in the HAlden Man-Machine LABoratory (HAMMLAB) before, it was also necessary to carry out research in methodology. In retrospect, it is clear that much of the methodological work is relevant to human-machine research in general, and not only to research on human error. The purpose of this report is, therefore, to give practitioners and researchers an overview of the methodological parts of HEAP. The scope of the report is limited to methods used throughout the data acquisition process, i.e., data-collection methods, data-refinement methods, and measurement methods. The data-collection methods include various types of verbal protocols, simulator logs, questionnaires, and interviews. Data-refinement methods involve different applications of the Eyecon system, a flexible data-refinement tool, and small computer programs used for rearranging, reformatting, and aggregating raw-data. Measurement methods involve assessment of diagnostic behaviour, erroneous actions, complexity, task/system performance, situation awareness, and workload. The report concludes that the data-collection methods are generally both reliable and efficient. The data-refinement methods, however, should be easier to use in order to facilitate explorative analyses. Although the series of experiments provided an opportunity for measurement validation, there are still uncertainties connected to several measures, due to their reliability still being unknown. (Author). 58 refs.,7 tabs

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 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

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.

Latent human error analysis and efficient improvement strategies by fuzzy TOPSIS in aviation maintenance tasks.

Science.gov (United States)

Chiu, Ming-Chuan; Hsieh, Min-Chih

2016-05-01

The purposes of this study were to develop a latent human error analysis process, to explore the factors of latent human error in aviation maintenance tasks, and to provide an efficient improvement strategy for addressing those errors. First, we used HFACS and RCA to define the error factors related to aviation maintenance tasks. Fuzzy TOPSIS with four criteria was applied to evaluate the error factors. Results show that 1) adverse physiological states, 2) physical/mental limitations, and 3) coordination, communication, and planning are the factors related to airline maintenance tasks that could be addressed easily and efficiently. This research establishes a new analytic process for investigating latent human error and provides a strategy for analyzing human error using fuzzy TOPSIS. Our analysis process complements shortages in existing methodologies by incorporating improvement efficiency, and it enhances the depth and broadness of human error analysis methodology. Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.

Compensating for Type-I Errors in Video Quality Assessment

DEFF Research Database (Denmark)

Brunnström, Kjell; Tavakoli, Samira; Søgaard, Jacob

2015-01-01

This paper analyzes the impact on compensating for Type-I errors in video quality assessment. A Type-I error is to incorrectly conclude that there is an effect. The risk increases with the number of comparisons that are performed in statistical tests. Type-I errors are an issue often neglected...

Analysis of human error and organizational deficiency in events considering risk significance

International Nuclear Information System (INIS)

Lee, Yong Suk; Kim, Yoonik; Kim, Say Hyung; Kim, Chansoo; Chung, Chang Hyun; Jung, Won Dea

2004-01-01

In this study, we analyzed human and organizational deficiencies in the trip events of Korean nuclear power plants. K-HPES items were used in human error analysis, and the organizational factors by Jacobs and Haber were used for organizational deficiency analysis. We proposed the use of CCDP as a risk measure to consider risk information in prioritizing K-HPES items and organizational factors. Until now, the risk significance of events has not been considered in human error and organizational deficiency analysis. Considering the risk significance of events in the process of analysis is necessary for effective enhancement of nuclear power plant safety by focusing on causes of human error and organizational deficiencies that are associated with significant risk

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 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.

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 Factor Modelling in the Risk Assessment of Port Manoeuvers

Directory of Open Access Journals (Sweden)

Teresa Abramowicz-Gerigk

2015-09-01

Full Text Available The documentation of human factor influence on the scenario development in maritime accidents compared with expert methods is commonly used as a basis in the process of setting up safety regulations and instructions. The new accidents and near misses show the necessity for further studies in determining the human factor influence on both risk acceptance criteria and development of risk control options for the manoeuvers in restricted waters. The paper presents the model of human error probability proposed for the assessment of ship masters and marine pilots' error decision and its influence on the risk of port manoeuvres.

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

Review of human error analysis methodologies and case study for accident management

International Nuclear Information System (INIS)

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

1998-03-01

In this research, we tried to establish the requirements for the development of a new human error analysis method. To achieve this goal, we performed a case study as following steps; 1. review of the existing HEA methods 2. selection of those methods which are considered to be appropriate for the analysis of operator's tasks in NPPs 3. choice of tasks for the application, selected for the case study: HRMS (Human reliability management system), PHECA (Potential Human Error Cause Analysis), CREAM (Cognitive Reliability and Error Analysis Method). And, as the tasks for the application, 'bleed and feed operation' and 'decision-making for the reactor cavity flooding' tasks are chosen. We measured the applicability of the selected methods to the NPP tasks, and evaluated the advantages and disadvantages between each method. The three methods are turned out to be applicable for the prediction of human error. We concluded that both of CREAM and HRMS are equipped with enough applicability for the NPP tasks, however, compared two methods. CREAM is thought to be more appropriate than HRMS from the viewpoint of overall requirements. The requirements for the new HEA method obtained from the study can be summarized as follows; firstly, it should deal with cognitive error analysis, secondly, it should have adequate classification system for the NPP tasks, thirdly, the description on the error causes and error mechanisms should be explicit, fourthly, it should maintain the consistency of the result by minimizing the ambiguity in each step of analysis procedure, fifty, it should be done with acceptable human resources. (author). 25 refs., 30 tabs., 4 figs

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.

A human factors needs assessment and planning study

International Nuclear Information System (INIS)

Price, H.E.; Van Cott, H.P.

1982-06-01

A study was done to assess the need for human factors research, development, and regulatory action in the Atomic Energy Control Board. Further study or development in nine human factors areas is proposed. The urgency, schedule, and resources judged to be necessary for the proposed efforts are estimated. Special emphasis is placed on the need for task analysis information, for the evaluation of control room and maintenance human engineering, and for the development of an improved human error reporting system

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 and Uncertainty in the Accuracy Assessment of Land Cover Maps

Science.gov (United States)

Sarmento, Pedro Alexandre Reis

Traditionally the accuracy assessment of land cover maps is performed through the comparison of these maps with a reference database, which is intended to represent the "real" land cover, being this comparison reported with the thematic accuracy measures through confusion matrixes. Although, these reference databases are also a representation of reality, containing errors due to the human uncertainty in the assignment of the land cover class that best characterizes a certain area, causing bias in the thematic accuracy measures that are reported to the end users of these maps. The main goal of this dissertation is to develop a methodology that allows the integration of human uncertainty present in reference databases in the accuracy assessment of land cover maps, and analyse the impacts that uncertainty may have in the thematic accuracy measures reported to the end users of land cover maps. The utility of the inclusion of human uncertainty in the accuracy assessment of land cover maps is investigated. Specifically we studied the utility of fuzzy sets theory, more precisely of fuzzy arithmetic, for a better understanding of human uncertainty associated to the elaboration of reference databases, and their impacts in the thematic accuracy measures that are derived from confusion matrixes. For this purpose linguistic values transformed in fuzzy intervals that address the uncertainty in the elaboration of reference databases were used to compute fuzzy confusion matrixes. The proposed methodology is illustrated using a case study in which the accuracy assessment of a land cover map for Continental Portugal derived from Medium Resolution Imaging Spectrometer (MERIS) is made. The obtained results demonstrate that the inclusion of human uncertainty in reference databases provides much more information about the quality of land cover maps, when compared with the traditional approach of accuracy assessment of land cover maps. None

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

Human error and the problem of causality in analysis of accidents

DEFF Research Database (Denmark)

Rasmussen, Jens

1990-01-01

, designers or managers have played a major role. There are, however, several basic problems in analysis of accidents and identification of human error. This paper addresses the nature of causal explanations and the ambiguity of the rules applied for identification of the events to include in analysis......Present technology is characterized by complexity, rapid change and growing size of technical systems. This has caused increasing concern with the human involvement in system safety. Analyses of the major accidents during recent decades have concluded that human errors on part of operators...

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.

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)

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)

CTER—Rapid estimation of CTF parameters with error assessment

Energy Technology Data Exchange (ETDEWEB)

Penczek, Pawel A., E-mail: Pawel.A.Penczek@uth.tmc.edu [Department of Biochemistry and Molecular Biology, The University of Texas Medical School, 6431 Fannin MSB 6.220, Houston, TX 77054 (United States); Fang, Jia [Department of Biochemistry and Molecular Biology, The University of Texas Medical School, 6431 Fannin MSB 6.220, Houston, TX 77054 (United States); Li, Xueming; Cheng, Yifan [The Keck Advanced Microscopy Laboratory, Department of Biochemistry and Biophysics, University of California, San Francisco, CA 94158 (United States); Loerke, Justus; Spahn, Christian M.T. [Institut für Medizinische Physik und Biophysik, Charité – Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin (Germany)

2014-05-01

In structural electron microscopy, the accurate estimation of the Contrast Transfer Function (CTF) parameters, particularly defocus and astigmatism, is of utmost importance for both initial evaluation of micrograph quality and for subsequent structure determination. Due to increases in the rate of data collection on modern microscopes equipped with new generation cameras, it is also important that the CTF estimation can be done rapidly and with minimal user intervention. Finally, in order to minimize the necessity for manual screening of the micrographs by a user it is necessary to provide an assessment of the errors of fitted parameters values. In this work we introduce CTER, a CTF parameters estimation method distinguished by its computational efficiency. The efficiency of the method makes it suitable for high-throughput EM data collection, and enables the use of a statistical resampling technique, bootstrap, that yields standard deviations of estimated defocus and astigmatism amplitude and angle, thus facilitating the automation of the process of screening out inferior micrograph data. Furthermore, CTER also outputs the spatial frequency limit imposed by reciprocal space aliasing of the discrete form of the CTF and the finite window size. We demonstrate the efficiency and accuracy of CTER using a data set collected on a 300 kV Tecnai Polara (FEI) using the K2 Summit DED camera in super-resolution counting mode. Using CTER we obtained a structure of the 80S ribosome whose large subunit had a resolution of 4.03 Å without, and 3.85 Å with, inclusion of astigmatism parameters. - Highlights: • We describe methodology for estimation of CTF parameters with error assessment. • Error estimates provide means for automated elimination of inferior micrographs. • High computational efficiency allows real-time monitoring of EM data quality. • Accurate CTF estimation yields structure of the 80S human ribosome at 3.85 Å.

Statistical evaluation of major human errors during the development of new technological systems

International Nuclear Information System (INIS)

Campbell, G; Ott, K.O.

1979-01-01

Statistical procedures are presented to evaluate major human errors during the development of a new system, errors that have led or can lead to accidents or major failures. The first procedure aims at estimating the average residual occurrence rate for s or major failures after several have occurred. The procedure is solely based on the historical record. Certain idealizations are introduced that allow the application of a sound statistical evaluation procedure. These idealizations are practically realized to a sufficient degree such that the proposed estimation procedure yields meaningful results, even for situations with a sparse data base, represented by very few accidents. Under the assumption that the possible human-error-related failure times have exponential distributions, the statistical technique of isotonic regression is proposed to estimate the failure rates due to human design error at the failure times of the system. The last value in the sequence of estimates gives the residual accident chance. In addition, theactual situation is tested against the hypothesis that the failure rate of the system remains constant over time. This test determines the chance for a decreasing failure rate being incidental, rather than an indication of an actual learning process. Both techniques can be applied not merely to a single system but to an entire series of similar systems that a technology would generate, enabling the assessment of technological improvement. For the purpose of illustration, the nuclear decay of isotopes was chosen as an example, since the assumptions of the model are rigorously satisfied in this case. This application shows satisfactory agreement of the estimated and actual failure rates (which are exactly known in this example), although the estimation was deliberately based on a sparse historical record

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

Student Self-Assessment and Faculty Assessment of Performance in an Interprofessional Error Disclosure Simulation Training Program.

Science.gov (United States)

Poirier, Therese I; Pailden, Junvie; Jhala, Ray; Ronald, Katie; Wilhelm, Miranda; Fan, Jingyang

2017-04-01

Objectives. To conduct a prospective evaluation for effectiveness of an error disclosure assessment tool and video recordings to enhance student learning and metacognitive skills while assessing the IPEC competencies. Design. The instruments for assessing performance (planning, communication, process, and team dynamics) in interprofessional error disclosure were developed. Student self-assessment of performance before and after viewing the recordings of their encounters were obtained. Faculty used a similar instrument to conduct real-time assessments. An instrument to assess achievement of the Interprofessional Education Collaborative (IPEC) core competencies was developed. Qualitative data was reviewed to determine student and faculty perceptions of the simulation. Assessment. The interprofessional simulation training involved a total of 233 students (50 dental, 109 nursing and 74 pharmacy). Use of video recordings made a significant difference in student self-assessment for communication and process categories of error disclosure. No differences in student self-assessments were noted among the different professions. There were differences among the family member affects for planning and communication for both pre-video and post-video data. There were significant differences between student self-assessment and faculty assessment for all paired comparisons, except communication in student post-video self-assessment. Students' perceptions of achievement of the IPEC core competencies were positive. Conclusion. The use of assessment instruments and video recordings may have enhanced students' metacognitive skills for assessing performance in interprofessional error disclosure. The simulation training was effective in enhancing perceptions on achievement of IPEC core competencies. This enhanced assessment process appeared to enhance learning about the skills needed for interprofessional error disclosure.

Error-Based Accidents and Security Incidents in Nuclear Materials Management

International Nuclear Information System (INIS)

Pond, Daniel J.; Greitzer, Frank L.

2005-01-01

Hazard and risk assessments, along with human error analysis and mitigation techniques, have long been mainstays of effective safety programs. These tools have revealed that worker errors contributing to or resulting in accidents are often the consequence of ineffective system conditions, process features, or individual employee characteristics. At Los Alamos National Laboratory (LANL), security, safety, human error, and organizational analysts determined that the system-induced human errors that make accidents more likely also are contributing to security incidents. A similar set of system conditions has been found to underlie deliberate, non-malevolent deviations from proper security practices - termed breaches - that also can result in a security incident. In fiscal-year (FY) 2002, LANL's Security Division therefore established the ESTHER (Enhanced Security Through Human Error Reduction) program to identify and reduce the influence of the factors that underlie employee errors and breaches and, in turn, security incidents. Recognizing the potential benefits of this program and approach, in FY2004 the Department of Energy (DOE) Office of Security Policy (DOE-SO) funded an expansion of ESTHER implementation to the causal assessment and reporting of security incidents at other DOE sites. This presentation will focus on three applications of error/breach assessment and mitigation techniques. One use is proactive, accomplished through the elimination of contributors to error, whereas two are reactive, implemented in response to accidents or security incidents as well as to near misses, to prevent recurrence. The human performance and safety bases of these techniques will be detailed. Associated tools - including computer-based assessment training and web-based incident reporting modules developed by Pacific Northwest National Laboratory - will be discussed

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)

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.)

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)

Quantitative evaluation of the impact of human reliability in risk assessment for nuclear power plants

International Nuclear Information System (INIS)

Samanta, P.K.

1981-01-01

The role of human beings in the safe operation of a nuclear power plant has been a matter of concern. This study describes methods for the quantitative description of that role and its impact on the risk from nuclear power plants. The impact of human errors was calculated by observing the changes in risk parameters, such as core melt probability, release category probabilities, accident sequence probabilities and system unavailabilities due to changes in the contribution to unavailablity of human errors, within the framework of risk assessment methodology. It was found that for operational pressurized water reactors the opportunity for reduction in core melt probability by reducing the human error rates without simultaneous reduction of hardware failures is limited, but that core melt probability would significantly increase as human error rates increased. More importantly, most of the dominant accident sequences showed a significant increase in their probabilities with an increase in human error rates. Release categories resulting in high consequences showed a much larger sensitivity to human errors than categories resulting in low consequences. A combination of structural importance and reliability importance measure was used to describe the importance of individual errors

SLIM-MAUD - a computer based technique for human reliability assessment

International Nuclear Information System (INIS)

Embrey, D.E.

1985-01-01

The Success Likelihood Index Methodology (SLIM) is a widely applicable technique which can be used to assess human error probabilities in both proceduralized and cognitive tasks (i.e. those involving decision making, problem solving, etc.). It assumes that expert assessors are able to evaluate the relative importance (or weights) of different factors called Performance Shaping Factors (PSFs), in determining the likelihood of error for the situations being assessed. Typical PSFs are the extent to which good procedures are available, operators are adequately trained, the man-machine interface is well designed, etc. If numerical ratings are made of the PSFs for the specific tasks being evaluated, these can be combined with the weights to give a numerical index, called the Success Likelihood Index (SLI). The SLI represents, in numerical form, the overall assessment of the experts of the likelihood of task success. The SLI can be subsequently transformed to a corresponding human error probability (HEP) estimate. The latest form of the SLIM technique is implemented using a microcomputer based system called MAUD (Multi-Attribute Utility Decomposition), the resulting technique being called SLIM-MAUD. A detailed description of the SLIM-MAUD technique and case studies of applications are available. An illustrative example of the application of SLIM-MAUD in probabilistic risk assessment is given

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)

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.

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 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.

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

Measurement Rounding Errors in an Assessment Model of Project Led Engineering Education

Directory of Open Access Journals (Sweden)

Francisco Moreira

2009-11-01

Full Text Available This paper analyzes the rounding errors that occur in the assessment of an interdisciplinary Project-Led Education (PLE process implemented in the Integrated Master degree on Industrial Management and Engineering (IME at University of Minho. PLE is an innovative educational methodology which makes use of active learning, promoting higher levels of motivation and students’ autonomy. The assessment model is based on multiple evaluation components with different weights. Each component can be evaluated by several teachers involved in different Project Supporting Courses (PSC. This model can be affected by different types of errors, namely: (1 rounding errors, and (2 non-uniform criteria of rounding the grades. A rigorous analysis of the assessment model was made and the rounding errors involved on each project component were characterized and measured. This resulted in a global maximum error of 0.308 on the individual student project grade, in a 0 to 100 scale. This analysis intended to improve not only the reliability of the assessment results, but also teachers’ awareness of this problem. Recommendations are also made in order to improve the assessment model and reduce the rounding errors as much as possible.

Assessment of the uncertainty associated with systematic errors in digital instruments: an experimental study on offset errors

International Nuclear Information System (INIS)

Attivissimo, F; Giaquinto, N; Savino, M; Cataldo, A

2012-01-01

This paper deals with the assessment of the uncertainty due to systematic errors, particularly in A/D conversion-based instruments. The problem of defining and assessing systematic errors is briefly discussed, and the conceptual scheme of gauge repeatability and reproducibility is adopted. A practical example regarding the evaluation of the uncertainty caused by the systematic offset error is presented. The experimental results, obtained under various ambient conditions, show that modelling the variability of systematic errors is more problematic than suggested by the ISO 5725 norm. Additionally, the paper demonstrates the substantial difference between the type B uncertainty evaluation, obtained via the maximum entropy principle applied to manufacturer's specifications, and the type A (experimental) uncertainty evaluation, which reflects actually observable reality. Although it is reasonable to assume a uniform distribution of the offset error, experiments demonstrate that the distribution is not centred and that a correction must be applied. In such a context, this work motivates a more pragmatic and experimental approach to uncertainty, with respect to the directions of supplement 1 of GUM. (paper)

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

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

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

Intraoperative visualization and assessment of electromagnetic tracking error

Science.gov (United States)

Harish, Vinyas; Ungi, Tamas; Lasso, Andras; MacDonald, Andrew; Nanji, Sulaiman; Fichtinger, Gabor

2015-03-01

Electromagnetic tracking allows for increased flexibility in designing image-guided interventions, however it is well understood that electromagnetic tracking is prone to error. Visualization and assessment of the tracking error should take place in the operating room with minimal interference with the clinical procedure. The goal was to achieve this ideal in an open-source software implementation in a plug and play manner, without requiring programming from the user. We use optical tracking as a ground truth. An electromagnetic sensor and optical markers are mounted onto a stylus device, pivot calibrated for both trackers. Electromagnetic tracking error is defined as difference of tool tip position between electromagnetic and optical readings. Multiple measurements are interpolated into the thin-plate B-spline transform visualized in real time using 3D Slicer. All tracked devices are used in a plug and play manner through the open-source SlicerIGT and PLUS extensions of the 3D Slicer platform. Tracking error was measured multiple times to assess reproducibility of the method, both with and without placing ferromagnetic objects in the workspace. Results from exhaustive grid sampling and freehand sampling were similar, indicating that a quick freehand sampling is sufficient to detect unexpected or excessive field distortion in the operating room. The software is available as a plug-in for the 3D Slicer platforms. Results demonstrate potential for visualizing electromagnetic tracking error in real time for intraoperative environments in feasibility clinical trials in image-guided interventions.

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)

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)

Human reliability

International Nuclear Information System (INIS)

Embrey, D.E.

1987-01-01

Concepts and techniques of human reliability have been developed and are used mostly in probabilistic risk assessment. For this, the major application of human reliability assessment has been to identify the human errors which have a significant effect on the overall safety of the system and to quantify the probability of their occurrence. Some of the major issues within human reliability studies are reviewed and it is shown how these are applied to the assessment of human failures in systems. This is done under the following headings; models of human performance used in human reliability assessment, the nature of human error, classification of errors in man-machine systems, practical aspects, human reliability modelling in complex situations, quantification and examination of human reliability, judgement based approaches, holistic techniques and decision analytic approaches. (UK)

Classifying and quantifying human error in routine tasks in nuclear power plants

International Nuclear Information System (INIS)

Pederson, O.M.; Rasmussen, J.; Carnino, A.; Gagnolet, P.; Griffon, M.; Mancini, G.

1982-01-01

This paper results from the work of the OECD/NEA-CSNI Group of Experts on Human Error Data and Assessment. It proposes a classification system (or taxonomy) for use in reporting events involving human malfunction, especially those occurring during the execution of routine tasks. A set of data collection sheets based on this taxonomy has been designed. They include the information needed in order to ensure adequate quality and coherence of the raw data. The sources from which the various data should be obtainable are identified, as are the persons who should analyze them. Improving data collection systems is an iterative process. Therefore Group members are currently making trial applications of the taxonomy to previously analysed real incidents. Results from the initial round of trials are presented and discussed

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

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)

The commission errors search and assessment (CESA) method

Energy Technology Data Exchange (ETDEWEB)

Reer, B.; Dang, V. N

2007-05-15

Errors of Commission (EOCs) refer to the performance of inappropriate actions that aggravate a situation. In Probabilistic Safety Assessment (PSA) terms, they are human failure events that result from the performance of an action. This report presents the Commission Errors Search and Assessment (CESA) method and describes the method in the form of user guidance. The purpose of the method is to identify risk-significant situations with a potential for EOCs in a predictive analysis. The main idea underlying the CESA method is to catalog the key actions that are required in the procedural response to plant events and to identify specific scenarios in which these candidate actions could erroneously appear to be required. The catalog of required actions provides a basis for a systematic search of context-action combinations. To focus the search towards risk-significant scenarios, the actions that are examined in the CESA search are prioritized according to the importance of the systems and functions that are affected by these actions. The existing PSA provides this importance information; the Risk Achievement Worth or Risk Increase Factor values indicate the systems/functions for which an EOC contribution would be more significant. In addition, the contexts, i.e. PSA scenarios, for which the EOC opportunities are reviewed are also prioritized according to their importance (top sequences or cut sets). The search through these context-action combinations results in a set of EOC situations to be examined in detail. CESA has been applied in a plant-specific pilot study, which showed the method to be feasible and effective in identifying plausible EOC opportunities. This experience, as well as the experience with other EOC analyses, showed that the quantification of EOCs remains an issue. The quantification difficulties and the outlook for their resolution conclude the report. (author)

The commission errors search and assessment (CESA) method

International Nuclear Information System (INIS)

Reer, B.; Dang, V. N.

2007-05-01

Errors of Commission (EOCs) refer to the performance of inappropriate actions that aggravate a situation. In Probabilistic Safety Assessment (PSA) terms, they are human failure events that result from the performance of an action. This report presents the Commission Errors Search and Assessment (CESA) method and describes the method in the form of user guidance. The purpose of the method is to identify risk-significant situations with a potential for EOCs in a predictive analysis. The main idea underlying the CESA method is to catalog the key actions that are required in the procedural response to plant events and to identify specific scenarios in which these candidate actions could erroneously appear to be required. The catalog of required actions provides a basis for a systematic search of context-action combinations. To focus the search towards risk-significant scenarios, the actions that are examined in the CESA search are prioritized according to the importance of the systems and functions that are affected by these actions. The existing PSA provides this importance information; the Risk Achievement Worth or Risk Increase Factor values indicate the systems/functions for which an EOC contribution would be more significant. In addition, the contexts, i.e. PSA scenarios, for which the EOC opportunities are reviewed are also prioritized according to their importance (top sequences or cut sets). The search through these context-action combinations results in a set of EOC situations to be examined in detail. CESA has been applied in a plant-specific pilot study, which showed the method to be feasible and effective in identifying plausible EOC opportunities. This experience, as well as the experience with other EOC analyses, showed that the quantification of EOCs remains an issue. The quantification difficulties and the outlook for their resolution conclude the report. (author)

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

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.)

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.

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

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

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

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)

The problem of assessing landmark error in geometric morphometrics: theory, methods, and modifications.

Science.gov (United States)

von Cramon-Taubadel, Noreen; Frazier, Brenda C; Lahr, Marta Mirazón

2007-09-01

Geometric morphometric methods rely on the accurate identification and quantification of landmarks on biological specimens. As in any empirical analysis, the assessment of inter- and intra-observer error is desirable. A review of methods currently being employed to assess measurement error in geometric morphometrics was conducted and three general approaches to the problem were identified. One such approach employs Generalized Procrustes Analysis to superimpose repeatedly digitized landmark configurations, thereby establishing whether repeat measures fall within an acceptable range of variation. The potential problem of this error assessment method (the "Pinocchio effect") is demonstrated and its effect on error studies discussed. An alternative approach involves employing Euclidean distances between the configuration centroid and repeat measures of a landmark to assess the relative repeatability of individual landmarks. This method is also potentially problematic as the inherent geometric properties of the specimen can result in misleading estimates of measurement error. A third approach involved the repeated digitization of landmarks with the specimen held in a constant orientation to assess individual landmark precision. This latter approach is an ideal method for assessing individual landmark precision, but is restrictive in that it does not allow for the incorporation of instrumentally defined or Type III landmarks. Hence, a revised method for assessing landmark error is proposed and described with the aid of worked empirical examples. (c) 2007 Wiley-Liss, Inc.

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)

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)

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...

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

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.

The assessment of cognitive errors using an observer-rated method.

Science.gov (United States)

Drapeau, Martin

2014-01-01

Cognitive Errors (CEs) are a key construct in cognitive behavioral therapy (CBT). Integral to CBT is that individuals with depression process information in an overly negative or biased way, and that this bias is reflected in specific depressotypic CEs which are distinct from normal information processing. Despite the importance of this construct in CBT theory, practice, and research, few methods are available to researchers and clinicians to reliably identify CEs as they occur. In this paper, the author presents a rating system, the Cognitive Error Rating Scale, which can be used by trained observers to identify and assess the cognitive errors of patients or research participants in vivo, i.e., as they are used or reported by the patients or participants. The method is described, including some of the more important rating conventions to be considered when using the method. This paper also describes the 15 cognitive errors assessed, and the different summary scores, including valence of the CEs, that can be derived from the method.

Nuclear power plant personnel errors in decision-making as an object of probabilistic risk assessment

International Nuclear Information System (INIS)

Reer, B.

1993-09-01

The integration of human error - also called man-machine system analysis (MMSA) - is an essential part of probabilistic risk assessment (PRA). A new method is presented which allows for a systematic and comprehensive PRA inclusions of decision-based errors due to conflicts or similarities. For the error identification procedure, new question techniques are developed. These errors are shown to be identified by looking at retroactions caused by subordinate goals as components of the overall safety relevant goal. New quantification methods for estimating situation-specific probabilities are developed. The factors conflict and similarity are operationalized in a way that allows their quantification based on informations which are usually available in PRA. The quantification procedure uses extrapolations and interpolations based on a poor set of data related to decision-based errors. Moreover, for passive errors in decision-making a completely new approach is presented where errors are quantified via a delay initiating the required action rather than via error probabilities. The practicability of this dynamic approach is demonstrated by a probabilistic analysis of the actions required during the total loss of feedwater event at the Davis-Besse plant 1985. The extensions of the ''classical'' PRA method developed in this work are applied to a MMSA of the decay heat removal (DHR) of the ''HTR-500''. Errors in decision-making - as potential roots of extraneous acts - are taken into account in a comprehensive and systematic manner. Five additional errors are identified. However, the probabilistic quantification results a nonsignificant increase of the DHR failure probability. (orig.) [de

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.

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

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 Probability Assessment During Maintenance Activities of Marine Systems

OpenAIRE

Rabiul Islam; Faisal Khan; Rouzbeh Abbassi; Vikram Garaniya

2018-01-01

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 personne...

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.

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

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)

Human factors assessment in PRA using Task Analysis Linked Evaluation Technique (TALENT)

International Nuclear Information System (INIS)

Wells, J.E.; Banks, W.W.

1991-01-01

Thirty years ago the US military and US aviation industry, and more recently, in response to the US Three Mile Island and USSR Chernobyl accidents, the US commercial nuclear power industry, acknowledged that human error, as an immediate precursor, and as a latent or indirect influence in the form of training, maintainability, inservice test, and surveillance programs, is a primary contributor to unreality and risk in complex high-reliability systems. A 1985 Nuclear Regulatory Commission (NRC) study of Licensee Event Reports (LERs) suggests that upwards of 65% of commercial nuclear system failures involve human error. Despite the magnitude and nature of human error cited in that study, there has been limited attention to personnel-centered issues, especially person-to-person issues involving group processes, management and organizational environment. The paper discusses NRC integration and applications research with respect to the Task Analysis Linked Evaluation Technique (TALENT) in risk assessment applications

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

Safety coaches in radiology: decreasing human error and minimizing patient harm

Energy Technology Data Exchange (ETDEWEB)

Dickerson, Julie M.; Adams, Janet M. [Cincinnati Children' s Hospital Medical Center, Department of Radiology, MLC 5031, Cincinnati, OH (United States); Koch, Bernadette L.; Donnelly, Lane F. [Cincinnati Children' s Hospital Medical Center, Department of Radiology, MLC 5031, Cincinnati, OH (United States); Cincinnati Children' s Hospital Medical Center, Department of Pediatrics, Cincinnati, OH (United States); Goodfriend, Martha A. [Cincinnati Children' s Hospital Medical Center, Department of Quality Improvement, Cincinnati, OH (United States)

2010-09-15

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program. (orig.)

Safety coaches in radiology: decreasing human error and minimizing patient harm

International Nuclear Information System (INIS)

Dickerson, Julie M.; Adams, Janet M.; Koch, Bernadette L.; Donnelly, Lane F.; Goodfriend, Martha A.

2010-01-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program. (orig.)

Safety coaches in radiology: decreasing human error and minimizing patient harm.

Science.gov (United States)

Dickerson, Julie M; Koch, Bernadette L; Adams, Janet M; Goodfriend, Martha A; Donnelly, Lane F

2010-09-01

Successful programs to improve patient safety require a component aimed at improving safety culture and environment, resulting in a reduced number of human errors that could lead to patient harm. Safety coaching provides peer accountability. It involves observing for safety behaviors and use of error prevention techniques and provides immediate feedback. For more than a decade, behavior-based safety coaching has been a successful strategy for reducing error within the context of occupational safety in industry. We describe the use of safety coaches in radiology. Safety coaches are an important component of our comprehensive patient safety program.

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.

Representing cognitive activities and errors in HRA trees

International Nuclear Information System (INIS)

Gertman, D.I.

1992-01-01

A graphic representation method is presented herein for adapting an existing technology--human reliability analysis (HRA) event trees, used to support event sequence logic structures and calculations--to include a representation of the underlying cognitive activity and corresponding errors associated with human performance. The analyst is presented with three potential means of representing human activity: the NUREG/CR-1278 HRA event tree approach; the skill-, rule- and knowledge-based paradigm; and the slips, lapses, and mistakes paradigm. The above approaches for representing human activity are integrated in order to produce an enriched HRA event tree -- the cognitive event tree system (COGENT)-- which, in turn, can be used to increase the analyst's understanding of the basic behavioral mechanisms underlying human error and the representation of that error in probabilistic risk assessment. Issues pertaining to the implementation of COGENT are also discussed

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 as the root cause of severe accidents at nuclear reactors

International Nuclear Information System (INIS)

Kovács Zoltán; Rýdzi, Stanislav

2017-01-01

A root cause is a factor inducing an undesirable event. It is feasible for root causes to be eliminated through technological process improvements. Human error was the root cause of all severe accidents at nuclear power plants. The TMI accident was caused by a series of human errors. The Chernobyl disaster occurred after a badly performed test of the turbogenerator at a reactor with design deficiencies, and in addition, the operators ignored the safety principles and disabled the safety systems. At Fukushima the tsunami risk was underestimated and the project failed to consider the specific issues of the site. The paper describes the severe accidents and points out the human errors that caused them. Also, provisions that might have eliminated those severe accidents are suggested. The fact that each severe accident occurred on a different type of reactor is relevant – no severe accident ever occurred twice at the same reactor type. The lessons learnt from the severe accidents and the safety measures implemented on reactor units all over the world seem to be effective. (orig.)

Complications: acknowledging, managing, and coping with human error.

Science.gov (United States)

Helo, Sevann; Moulton, Carol-Anne E

2017-08-01

Errors are inherent in medicine due to the imperfectness of human nature. Health care providers may have a difficult time accepting their fallibility, acknowledging mistakes, and disclosing errors. Fear of litigation, shame, blame, and concern about reputation are just some of the barriers preventing physicians from being more candid with their patients, despite the supporting body of evidence that patients cite poor communication and lack of transparency as primary drivers to file a lawsuit in the wake of a medical complication. Proper error disclosure includes a timely explanation of what happened, who was involved, why the error occurred, and how it will be prevented in the future. Medical mistakes afford the opportunity for individuals and institutions to be candid about their weaknesses while improving patient care processes. When a physician takes the Hippocratic Oath they take on a tremendous sense of responsibility for the care of their patients, and often bear the burden of their mistakes in isolation. Physicians may struggle with guilt, shame, and a crisis of confidence, which may thwart efforts to identify areas for improvement that can lead to meaningful change. Coping strategies for providers include discussing the event with others, seeking professional counseling, and implementing quality improvement projects. Physicians and health care organizations need to find adaptive ways to deal with complications that will benefit patients, providers, and their institutions.

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.

The safety assessment system based on virtual networked environment for evaluation on the hazards from human errors during decommissioning of nuclear facilities

International Nuclear Information System (INIS)

Jeong, Kwan Seong; Choi, Byung Seon; Moon, Jei Kwon; Hyun, Dong Jun; Lee, Jong Hwan; Kim, Ik June; Kang, Shin Young; Choi, Jong Won; Ahn, Sang Myeon; Lee, Jung Jun; Lee, Byung Sik

2016-01-01

This paper is intended to suggest a system for evaluation on the hazards from human errors during decommissioning of nuclear facilities. The system was developed under virtual networked environment. The innovative features are real-time changing direction of workers in a scenario and real-time measuring personal exposure dose and collective exposure dose. The system will be expected to be utilized as a training tool for improving familiarization of a workplace and for preventing workers from accidents. - Highlights: • A system for evaluation on the hazards from human errors during decommissioning of nuclear facilities. • Real-time changing direction of workers in a scenario. • Real-time measuring personal exposure dose and collective exposure dose. • A tool for improving familiarization of a workplace and for preventing workers from accidents.

When soft controls get slippery: User interfaces and human error

International Nuclear Information System (INIS)

Stubler, W.F.; O'Hara, J.M.

1998-01-01

Many types of products and systems that have traditionally featured physical control devices are now being designed with soft controls--input formats appearing on computer-based display devices and operated by a variety of input devices. A review of complex human-machine systems found that soft controls are particularly prone to some types of errors and may affect overall system performance and safety. This paper discusses the application of design approaches for reducing the likelihood of these errors and for enhancing usability, user satisfaction, and system performance and safety

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.

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

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...

Seismic-load-induced human errors and countermeasures using computer graphics in plant-operator communication

International Nuclear Information System (INIS)

Hara, Fumio

1988-01-01

This paper remarks the importance of seismic load-induced human errors in plant operation by delineating the characteristics of the task performance of human beings under seismic loads. It focuses on man-machine communication via multidimensional data like that conventionally displayed on large panels in a plant control room. It demonstrates a countermeasure to human errors using a computer graphics technique that conveys the global state of the plant operation to operators through cartoon-like, colored graphs in the form of faces that, with different facial expressions, show the plant safety status. (orig.)

Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

Energy Technology Data Exchange (ETDEWEB)

Koo, In Soo; Seo, Sang Mun; Park, Geun Ok (and others)

2008-08-15

It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel.

Development of the Human Error Management Criteria and the Job Aptitude Evaluation Criteria for Rail Safety Personnel

International Nuclear Information System (INIS)

Koo, In Soo; Seo, Sang Mun; Park, Geun Ok

2008-08-01

It has been estimated that up to 90% of all workplace accidents have human error as a cause. Human error has been widely recognized as a key factor in almost all the highly publicized accidents, including Daegu subway fire of February 18, 2003 killed 198 people and injured 147. Because most human behavior is 'unintentional', carried out automatically, root causes of human error should be carefully investigated and regulated by a legal authority. The final goal of this study is to set up some regulatory guidance that are supposed to be used by the korean rail organizations related to safety managements and the contents are : - to develop the regulatory guidance for managing human error, - to develop the regulatory guidance for managing qualifications of rail drivers - to develop the regulatory guidance for evaluating the aptitude of the safety-related personnel

Perancangan Fasilitas Kerja untuk Mereduksi Human Error

Directory of Open Access Journals (Sweden)

Harmein Nasution

2012-01-01

Full Text Available Work equipments and environment which are not design ergonomically can cause physical exhaustion to the workers. As a result of that physical exhaustion, many defects in the production lines can happen due to human error and also cause musculoskeletal complaints. To overcome, those effects, we occupied methods for analyzing the workers posture based on the SNQ (Standard Nordic Questionnaire, plibel, QEC (Quick Exposure Check and biomechanism. Moreover, we applied those methods for designing rolling machines and grip egrek ergono-mically, so that the defects on those production lines can be minimized.

Modelling the basic error tendencies of human operators

Energy Technology Data Exchange (ETDEWEB)

Reason, J.

1988-01-01

The paper outlines the primary structural features of human cognition: a limited, serial workspace interacting with a parallel distributed knowledge base. It is argued that the essential computational features of human cognition - to be captured by an adequate operator model - reside in the mechanisms by which stored knowledge structures are selected and brought into play. Two such computational 'primitives' are identified: similarity-matching and frequency-gambling. These two retrieval heuristics, it is argued, shape both the overall character of human performance (i.e. its heavy reliance on pattern-matching) and its basic error tendencies ('strong-but-wrong' responses, confirmation, similarity and frequency biases, and cognitive 'lock-up'). The various features of human cognition are integrated with a dynamic operator model capable of being represented in software form. This computer model, when run repeatedly with a variety of problem configurations, should produce a distribution of behaviours which, in toto, simulate the general character of operator performance.

Modelling the basic error tendencies of human operators

International Nuclear Information System (INIS)

Reason, J.

1988-01-01

The paper outlines the primary structural features of human cognition: a limited, serial workspace interacting with a parallel distributed knowledge base. It is argued that the essential computational features of human cognition - to be captured by an adequate operator model - reside in the mechanisms by which stored knowledge structures are selected and brought into play. Two such computational 'primitives' are identified: similarity-matching and frequency-gambling. These two retrieval heuristics, it is argued, shape both the overall character of human performance (i.e. its heavy reliance on pattern-matching) and its basic error tendencies ('strong-but-wrong' responses, confirmation, similarity and frequency biases, and cognitive 'lock-up'). The various features of human cognition are integrated with a dynamic operator model capable of being represented in software form. This computer model, when run repeatedly with a variety of problem configurations, should produce a distribution of behaviours which, in total, simulate the general character of operator performance. (author)

Modelling the basic error tendencies of human operators

International Nuclear Information System (INIS)

Reason, James

1988-01-01

The paper outlines the primary structural features of human cognition: a limited, serial workspace interacting with a parallel distributed knowledge base. It is argued that the essential computational features of human cognition - to be captured by an adequate operator model - reside in the mechanisms by which stored knowledge structures are selected and brought into play. Two such computational 'primitives' are identified: similarity-matching and frequency-gambling. These two retrieval heuristics, it is argued, shape both the overall character of human performance (i.e. its heavy reliance on pattern-matching) and its basic error tendencies ('strong-but-wrong' responses, confirmation, similarity and frequency biases, and cognitive 'lock-up'). The various features of human cognition are integrated with a dynamic operator model capable of being represented in software form. This computer model, when run repeatedly with a variety of problem configurations, should produce a distribution of behaviours which, in toto, simulate the general character of operator performance. (author)

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

Using human error theory to explore the supply of non-prescription medicines from community pharmacies.

Science.gov (United States)

Watson, M C; Bond, C M; Johnston, M; Mearns, K

2006-08-01

The importance of theory in underpinning interventions to promote effective professional practice is gaining recognition. The Medical Research Council framework for complex interventions has assisted in promoting awareness and adoption of theory into study design. Human error theory has previously been used by high risk industries but its relevance to healthcare settings and patient safety requires further investigation. This study used this theory as a framework to explore non-prescription medicine supply from community pharmacies. The relevance to other healthcare settings and behaviours is discussed. A 25% random sample was made of 364 observed consultations for non-prescription medicines. Each of the 91 consultations was assessed by two groups: a consensus group (stage 1) to identify common problems with the consultation process, and an expert group (stages 2 and 3) to apply human error theory to these consultations. Paired assessors (most of whom were pharmacists) categorised the perceived problems occurring in each consultation (stage 1). During stage 2 paired assessors from an expert group (comprising patient safety experts, community pharmacists and psychologists) considered whether each consultation was compliant with professional guidelines for the supply of pharmacy medicines. Each non-compliant consultation identified during stage 2 was then categorised as a slip/lapse, mistake, or violation using human error theory (stage 3). During stage 1 most consultations (n = 75, 83%) were deemed deficient in information exchange. At stage 2, paired assessors varied in attributing non-compliance to specific error types. Where agreement was achieved, the error type most often selected was "violation" (n = 27, 51.9%, stage 3). Consultations involving product requests were less likely to be guideline compliant than symptom presentations (OR 0.30, 95% CI 0.10 to 0.95, p = 0.05). The large proportion of consultations classified as violations suggests that either

A Benefit/Cost/Deficit (BCD) model for learning from human errors

International Nuclear Information System (INIS)

Vanderhaegen, Frederic; Zieba, Stephane; Enjalbert, Simon; Polet, Philippe

2011-01-01

This paper proposes an original model for interpreting human errors, mainly violations, in terms of benefits, costs and potential deficits. This BCD model is then used as an input framework to learn from human errors, and two systems based on this model are developed: a case-based reasoning system and an artificial neural network system. These systems are used to predict a specific human car driving violation: not respecting the priority-to-the-right rule, which is a decision to remove a barrier. Both prediction systems learn from previous violation occurrences, using the BCD model and four criteria: safety, for identifying the deficit or the danger; and opportunity for action, driver comfort, and time spent; for identifying the benefits or the costs. The application of learning systems to predict car driving violations gives a rate over 80% of correct prediction after 10 iterations. These results are validated for the non-respect of priority-to-the-right rule.

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

Refractive error assessment: influence of different optical elements and current limits of biometric techniques.

Science.gov (United States)

Ribeiro, Filomena; Castanheira-Dinis, Antonio; Dias, Joao Mendanha

2013-03-01

To identify and quantify sources of error on refractive assessment using exact ray tracing. The Liou-Brennan eye model was used as a starting point and its parameters were varied individually within a physiological range. The contribution of each parameter to refractive error was assessed using linear regression curve fits and Gaussian error propagation analysis. A MonteCarlo analysis quantified the limits of refractive assessment given by current biometric measurements. Vitreous and aqueous refractive indices are the elements that influence refractive error the most, with a 1% change of each parameter contributing to a refractive error variation of +1.60 and -1.30 diopters (D), respectively. In the phakic eye, axial length measurements taken by ultrasound (vitreous chamber depth, lens thickness, and anterior chamber depth [ACD]) were the most sensitive to biometric errors, with a contribution to the refractive error of 62.7%, 14.2%, and 10.7%, respectively. In the pseudophakic eye, vitreous chamber depth showed the highest contribution at 53.7%, followed by postoperative ACD at 35.7%. When optic measurements were considered, postoperative ACD was the most important contributor, followed by anterior corneal surface and its asphericity. A MonteCarlo simulation showed that current limits of refractive assessment are 0.26 and 0.28 D for the phakic and pseudophakic eye, respectively. The most relevant optical elements either do not have available measurement instruments or the existing instruments still need to improve their accuracy. Ray tracing can be used as an optical assessment technique, and may be the correct path for future personalized refractive assessment. Copyright 2013, SLACK Incorporated.

Healing assessment of tile sets for error tolerance in DNA self-assembly.

Science.gov (United States)

Hashempour, M; Mashreghian Arani, Z; Lombardi, F

2008-12-01

An assessment of the effectiveness of healing for error tolerance in DNA self-assembly tile sets for algorithmic/nano-manufacturing applications is presented. Initially, the conditions for correct binding of a tile to an existing aggregate are analysed using a Markovian approach; based on this analysis, it is proved that correct aggregation (as identified with a so-called ideal tile set) is not always met for the existing tile sets for nano-manufacturing. A metric for assessing tile sets for healing by utilising punctures is proposed. Tile sets are investigated and assessed with respect to features such as error (mismatched tile) movement, punctured area and bond types. Subsequently, it is shown that the proposed metric can comprehensively assess the healing effectiveness of a puncture type for a tile set and its capability to attain error tolerance for the desired pattern. Extensive simulation results are provided.

How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

Energy Technology Data Exchange (ETDEWEB)

Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee [Korea Atomic Research Institute, Daejeon (Korea, Republic of)

2014-10-15

The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

How to Cope with the Rare Human Error Events Involved with organizational Factors in Nuclear Power Plants

International Nuclear Information System (INIS)

Kim, Sa Kil; Luo, Meiling; Lee, Yong Hee

2014-01-01

The current human error guidelines (e.g. US DOD handbooks, US NRC Guidelines) are representative tools to prevent human errors. These tools, however, have limits that they do not adapt all operating situations and circumstances such as design base events. In other words, these tools are only adapted foreseeable standardized operating situations and circumstances. In this study, our research team proposed an evidence-based approach such as UK's safety case to coping with the rare human error events such as TMI, Chernobyl, Fukushima accidents. These accidents are representative events involved with rare human errors. Our research team defined the 'rare human errors' as the follow three characterized events; Extremely low frequency Extremely high complicated structure Extremely serious damage of human life and property A safety case is a structured argument, supported by evidence, intended to justify that a system is acceptably safe. The definition by UK defense standard 00-56 issue 4 states that such an evidence-based approach can be contrast with a prescriptive approach to safety certification, which require safety to be justified using a prescribed process. Safety managements and safety regulatory activities based on safety case are effective to control organizational factors in terms of integrated safety management. Especially safety issues relevant with public acceptance are useful to provide practical evidences to the public reasonably. European Union including UK has developed the concept of engineered safety management system to deal with public acceptance using the safety case. In Korea nuclear industry, the Korean Atomic Research Institute has firstly performed a basic research to adapt the safety case in the field of radioactive waste according to the IAEA SSG-23(KAERI/TR-4497, 4531). Excepting the radioactive waste, there is no try to adapt the safety case yet. Most incidents and accidents involved human during operating NPPs have a tendency

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

New classification of operators' human errors at overseas nuclear power plants and preparation of easy-to-use case sheets

International Nuclear Information System (INIS)

Takagawa, Kenichi

2004-01-01

At nuclear power plants, plant operators examine other human error cases, including those that occurred at other plants, so that they can learn from such experiences and avoid making similar errors again. Although there is little data available on errors made at domestic plants, nuclear operators in foreign countries are reporting even minor irregularities and signs of faults, and a large amount of data on human errors at overseas plants could be collected and examined. However, these overseas data have not been used effectively because most of them are poorly organized or not properly classified and are often hard to understand. Accordingly, we carried out a study on the cases of human errors at overseas power plants in order to help plant personnel clearly understand overseas experiences and avoid repeating similar errors, The study produced the following results, which were put to use at nuclear power plants and other facilities. (1) ''One-Point-Advice'' refers to a practice where a leader gives pieces of advice to his team of operators in order to prevent human errors before starting work. Based on this practice and those used in the aviation industry, we have developed a new method of classifying human errors that consists of four basic actions and three applied actions. (2) We used this new classification method to classify human errors made by operators at overseas nuclear power plants. The results show that the most frequent errors caused not by operators themselves but due to insufficient team monitoring, for which superiors and/or their colleagues were responsible. We therefore analyzed and classified possible factors contributing to insufficient team monitoring, and demonstrated that the frequent errors have also occurred at domestic power plants. (3) Using the new classification formula, we prepared a human error case sheets that is easy for plant personnel to understand. The sheets are designed to make data more understandable and easier to remember

Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR): Guide to data processing and revision: Part 2, Human error probability data entry and revision procedures

International Nuclear Information System (INIS)

Gilmore, W.E.; Gertman, D.I.; Gilbert, B.G.; Reece, W.J.

1988-11-01

The Nuclear Computerized Library for Assessing Reactor Reliability (NUCLARR) is an automated data base management system for processing and storing human error probability (HEP) and hardware component failure data (HCFD). The NUCLARR system software resides on an IBM (or compatible) personal micro-computer. Users can perform data base searches to furnish HEP estimates and HCFD rates. In this manner, the NUCLARR system can be used to support a variety of risk assessment activities. This volume, Volume 3 of a 5-volume series, presents the procedures used to process HEP and HCFD for entry in NUCLARR and describes how to modify the existing NUCLARR taxonomy in order to add either equipment types or action verbs. Volume 3 also specifies the various roles of the administrative staff on assignment to the NUCLARR Clearinghouse who are tasked with maintaining the data base, dealing with user requests, and processing NUCLARR data. 5 refs., 34 figs., 3 tabs

Human Factors Risk Analyses of a Doffing Protocol for Ebola-Level Personal Protective Equipment: Mapping Errors to Contamination.

Science.gov (United States)

Mumma, Joel M; Durso, Francis T; Ferguson, Ashley N; Gipson, Christina L; Casanova, Lisa; Erukunuakpor, Kimberly; Kraft, Colleen S; Walsh, Victoria L; Zimring, Craig; DuBose, Jennifer; Jacob, Jesse T

2018-03-05

Doffing protocols for personal protective equipment (PPE) are critical for keeping healthcare workers (HCWs) safe during care of patients with Ebola virus disease. We assessed the relationship between errors and self-contamination during doffing. Eleven HCWs experienced with doffing Ebola-level PPE participated in simulations in which HCWs donned PPE marked with surrogate viruses (ɸ6 and MS2), completed a clinical task, and were assessed for contamination after doffing. Simulations were video recorded, and a failure modes and effects analysis and fault tree analyses were performed to identify errors during doffing, quantify their risk (risk index), and predict contamination data. Fifty-one types of errors were identified, many having the potential to spread contamination. Hand hygiene and removing the powered air purifying respirator (PAPR) hood had the highest total risk indexes (111 and 70, respectively) and number of types of errors (9 and 13, respectively). ɸ6 was detected on 10% of scrubs and the fault tree predicted a 10.4% contamination rate, likely occurring when the PAPR hood inadvertently contacted scrubs during removal. MS2 was detected on 10% of hands, 20% of scrubs, and 70% of inner gloves and the predicted rates were 7.3%, 19.4%, 73.4%, respectively. Fault trees for MS2 and ɸ6 contamination suggested similar pathways. Ebola-level PPE can both protect and put HCWs at risk for self-contamination throughout the doffing process, even among experienced HCWs doffing with a trained observer. Human factors methodologies can identify error-prone steps, delineate the relationship between errors and self-contamination, and suggest remediation strategies.

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...

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)

Agreeableness and Conscientiousness as Predictors of University Students' Self/Peer-Assessment Rating Error

Science.gov (United States)

Birjandi, Parviz; Siyyari, Masood

2016-01-01

This paper presents the results of an investigation into the role of two personality traits (i.e. Agreeableness and Conscientiousness from the Big Five personality traits) in predicting rating error in the self-assessment and peer-assessment of composition writing. The average self/peer-rating errors of 136 Iranian English major undergraduates…

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.

Good people who try their best can have problems: recognition of human factors and how to minimise error.

Science.gov (United States)

Brennan, Peter A; Mitchell, David A; Holmes, Simon; Plint, Simon; Parry, David

2016-01-01

Human error is as old as humanity itself and is an appreciable cause of mistakes by both organisations and people. Much of the work related to human factors in causing error has originated from aviation where mistakes can be catastrophic not only for those who contribute to the error, but for passengers as well. The role of human error in medical and surgical incidents, which are often multifactorial, is becoming better understood, and includes both organisational issues (by the employer) and potential human factors (at a personal level). Mistakes as a result of individual human factors and surgical teams should be better recognised and emphasised. Attitudes and acceptance of preoperative briefing has improved since the introduction of the World Health Organization (WHO) surgical checklist. However, this does not address limitations or other safety concerns that are related to performance, such as stress and fatigue, emotional state, hunger, awareness of what is going on situational awareness, and other factors that could potentially lead to error. Here we attempt to raise awareness of these human factors, and highlight how they can lead to error, and how they can be minimised in our day-to-day practice. Can hospitals move from being "high risk industries" to "high reliability organisations"? Copyright © 2015 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

Energy Technology Data Exchange (ETDEWEB)

Callan, J.R.; Kelly, R.T.; Quinn, M.L. [Pacific Science and Engineering Group, San Diego, CA (United States)] [and others

1995-05-01

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.

Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance. Volume 1

International Nuclear Information System (INIS)

Callan, J.R.; Kelly, R.T.; Quinn, M.L.

1995-05-01

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

Human factors assessment in PRA using task analysis linked evaluation technique (TALENT)

International Nuclear Information System (INIS)

Wells, J.E.; Banks, W.W.

1990-01-01

Human error is a primary contributor to risk in complex high-reliability systems. A 1985 U.S. Nuclear Regulatory Commission (USNRC) study of licensee event reports (LERs) suggests that upwards of 65% of commercial nuclear system failures involve human error. Since then, the USNRC has initiated research to fully and properly integrate human errors into the probabilistic risk assessment (PRA) process. The resulting implementation procedure is known as the Task Analysis Linked Evaluation Technique (TALENT). As indicated, TALENT is a broad-based method for integrating human factors expertise into the PRA process. This process achieves results which: (1) provide more realistic estimates of the impact of human performance on nuclear power safety, (2) can be fully audited, (3) provide a firm technical base for equipment-centered and personnel-centered retrofit/redesign of plants enabling them to meet internally and externally imposed safety standards, and (4) yield human and hardware data capable of supporting inquiries into human performance issues that transcend the individual plant. The TALENT procedure is being field-tested to verify its effectiveness and utility. The objectives of the field-test are to examine (1) the operability of the process, (2) its acceptability to the users, and (3) its usefulness for achieving measurable improvements in the credibility of the analysis. The field-test will provide the information needed to enhance the TALENT process

Process error rates in general research applications to the Human ...

African Journals Online (AJOL)

Objective. To examine process error rates in applications for ethics clearance of health research. Methods. Minutes of 586 general research applications made to a human health research ethics committee (HREC) from April 2008 to March 2009 were examined. Rates of approval were calculated and reasons for requiring ...

Accounting for measurement error in human life history trade-offs using structural equation modeling.

Science.gov (United States)

Helle, Samuli

2018-03-01

Revealing causal effects from correlative data is very challenging and a contemporary problem in human life history research owing to the lack of experimental approach. Problems with causal inference arising from measurement error in independent variables, whether related either to inaccurate measurement technique or validity of measurements, seem not well-known in this field. The aim of this study is to show how structural equation modeling (SEM) with latent variables can be applied to account for measurement error in independent variables when the researcher has recorded several indicators of a hypothesized latent construct. As a simple example of this approach, measurement error in lifetime allocation of resources to reproduction in Finnish preindustrial women is modelled in the context of the survival cost of reproduction. In humans, lifetime energetic resources allocated in reproduction are almost impossible to quantify with precision and, thus, typically used measures of lifetime reproductive effort (e.g., lifetime reproductive success and parity) are likely to be plagued by measurement error. These results are contrasted with those obtained from a traditional regression approach where the single best proxy of lifetime reproductive effort available in the data is used for inference. As expected, the inability to account for measurement error in women's lifetime reproductive effort resulted in the underestimation of its underlying effect size on post-reproductive survival. This article emphasizes the advantages that the SEM framework can provide in handling measurement error via multiple-indicator latent variables in human life history studies. © 2017 Wiley Periodicals, Inc.

A human reliability assessment screening method for the NRU upgrade project

International Nuclear Information System (INIS)

Bremner, F.M.; Alsop, C.J.

1997-01-01

The National Research Universal (NRU) reactor is a 130MW, low pressure, heavy water cooled and moderated research reactor. The reactor is used for research, both in support of Canada's CANDU development program, and for a wide variety of other research applications. In addition, NRU plays an important part in the production of medical isotopes, e.g., generating 80% of worldwide supplies of Molybdenum-99. NRU is owned and operated by Atomic Energy of Canada Ltd. (AECL), and is currently undergoing upgrading as part of AECL's continuing commitment to operate their facilities in a safe manner. As part of these upgrades both deterministic and probabilistic safety assessments are being carried out. It was recognized that the assignment of Human Error Probabilities (HEPs) is an important part of the Probabilistic Safety Assessment (PSA) studies, particularly for a facility whose design predates modern ergonomic practices, and which will undergo a series of backfitted modifications whilst continuing to operate. A simple Human Reliability Assessment (HRA) screening method, looking at both pre- and post-accident errors, was used in the initial safety studies. However, following review of this method within AECL and externally by the regulator, it was judged that benefits could be gained for future error reduction by including additional features, as later described in this document. The HRA development project consisted of several stages; needs analysis, literature review, development of method (including testing and evaluation), and implementation. This paper discusses each of these stages in further detail. (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

The current approach to human error and blame in the NHS.

Science.gov (United States)

Ottewill, Melanie

There is a large body of research to suggest that serious errors are widespread throughout medicine. The traditional response to these adverse events has been to adopt a 'person approach' - blaming the individual seen as 'responsible'. The culture of medicine is highly complicit in this response. Such an approach results in enormous personal costs to the individuals concerned and does little to address the root causes of errors and thus prevent their recurrence. Other industries, such as aviation, where safety is a paramount concern and which have similar structures to the medical profession, have, over the past decade or so, adopted a 'systems' approach to error, recognizing that human error is ubiquitous and inevitable and that systems need to be developed with this in mind. This approach has been highly successful, but has necessitated, first and foremost, a cultural shift. It is in the best interests of patients, and medical professionals alike, that such a shift is embraced in the NHS.

Basic design of multimedia system for the representation of human error cases in nuclear power plants

Energy Technology Data Exchange (ETDEWEB)

Lee, Jung Woon; Park, Geun Ok [Korea Atomic Energy Research Institute, Taejon (Korea, Republic of)

1994-04-01

We have developed a multimedia system for the representation of human error cases with the education and training on human errors can be done effectively. The followings are major topics during the basic design; 1 Establishment of a basic concept for representing human error cases using multimedia, 2 Establishment of a design procedure for the multimedia system, 3 Establishment of a hardware and software environment for operating the multimedia system, 4 Design of multimedia input and output interfaces. In order to verify the results of this basic design, we implemented the basic design with an incident triggered by operator`s misaction which occurred at Uljin NPP Unit 1. (Author) 12 refs., 30 figs.,.

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

A development of the Human Factors Assessment Guide for the Study of Erroneous Human Behaviors in Nuclear Power Plants

International Nuclear Information System (INIS)

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

2014-01-01

The aim of this paper is to describe a human factors assessment guide for the study of the erroneous characteristic of operators in nuclear power plants (NPPs). We think there are still remaining the human factors issues such as an uneasy emotion, fatigue and stress, varying mental workload situation by digital environment, and various new type of unsafe response to digital interface for better decisions, although introducing an advanced main control room. These human factors issues may not be resolved through the current human reliability assessment which evaluates the total probability of a human error occurring throughout the completion of a specific task. This paper provides an assessment guide for the human factors issues a set of experimental methodology, and presents an assessment case of measurement and analysis especially from neuro physiology approach. It would be the most objective psycho-physiological research technique on human performance for a qualitative analysis considering the safety aspects. This paper can be trial to experimental assessment of erroneous behaviors and their influencing factors, and it can be used as an index for recognition and a method to apply human factors engineering V and V, which is required as a mandatory element of human factor engineering program plan for a NPP design

A development of the Human Factors Assessment Guide for the Study of Erroneous Human Behaviors in Nuclear Power Plants

Energy Technology Data Exchange (ETDEWEB)

Oh, Yeon Ju; Lee, Yong Hee; Jang, Tong Il; Kim, Sa Kil [Korea Atomic Energy Research Institute, Daejeon (Korea, Republic of)

2014-08-15

The aim of this paper is to describe a human factors assessment guide for the study of the erroneous characteristic of operators in nuclear power plants (NPPs). We think there are still remaining the human factors issues such as an uneasy emotion, fatigue and stress, varying mental workload situation by digital environment, and various new type of unsafe response to digital interface for better decisions, although introducing an advanced main control room. These human factors issues may not be resolved through the current human reliability assessment which evaluates the total probability of a human error occurring throughout the completion of a specific task. This paper provides an assessment guide for the human factors issues a set of experimental methodology, and presents an assessment case of measurement and analysis especially from neuro physiology approach. It would be the most objective psycho-physiological research technique on human performance for a qualitative analysis considering the safety aspects. This paper can be trial to experimental assessment of erroneous behaviors and their influencing factors, and it can be used as an index for recognition and a method to apply human factors engineering V and V, which is required as a mandatory element of human factor engineering program plan for a NPP design.

Cognitive environment simulation: An artificial intelligence system for human performance assessment: Modeling human intention formation: [Technical report, May 1986-June 1987

International Nuclear Information System (INIS)

Woods, D.D.; Roth, E.M.; Pople, H. Jr.

1987-11-01

This report documents the results of Phase II of a three phase research program to develop and validate improved methods to model the cognitive behavior of nuclear power plant (NPP) personnel. In Phase II a dynamic simulation capability for modeling how people form intentions to act in NPP emergency situations was developed based on techniques from artificial intelligence. This modeling tool, Cognitive Environment Simulation or CES, simulates the cognitive processes that determine situation assessment and intention formation. It can be used to investigate analytically what situations and factors lead to intention failures, what actions follow from intention failures (e.g., errors of omission, errors of commission, common mode errors), the ability to recover from errors or additional machine failures, and the effects of changes in the NPP person-machine system. The Cognitive Reliability Assessment Technique (or CREATE) was also developed in Phase II to specify how CES can be used to enhance the measurement of the human contribution to risk in probabilistic risk assessment (PRA) studies. 43 refs., 20 figs., 1 tab

Assessment of errors and uncertainty patterns in GIA modeling

DEFF Research Database (Denmark)

Barletta, Valentina Roberta; Spada, G.

2012-01-01

During the last decade many efforts have been devoted to the assessment of global sea level rise and to the determination of the mass balance of continental ice sheets. In this context, the important role of glacial-isostatic adjustment (GIA) has been clearly recognized. Yet, in many cases only one......, such as time-evolving shorelines and paleo-coastlines. In this study we quantify these uncertainties and their propagation in GIA response using a Monte Carlo approach to obtain spatio-temporal patterns of GIA errors. A direct application is the error estimates in ice mass balance in Antarctica and Greenland...

The Development of Marine Accidents Human Reliability Assessment Approach: HEART Methodology and MOP Model

Directory of Open Access Journals (Sweden)

Ludfi Pratiwi Bowo

2017-06-01

Full Text Available Humans are one of the important factors in the assessment of accidents, particularly marine accidents. Hence, studies are conducted to assess the contribution of human factors in accidents. There are two generations of Human Reliability Assessment (HRA that have been developed. Those methodologies are classified by the differences of viewpoints of problem-solving, as the first generation and second generation. The accident analysis can be determined using three techniques of analysis; sequential techniques, epidemiological techniques and systemic techniques, where the marine accidents are included in the epidemiological technique. This study compares the Human Error Assessment and Reduction Technique (HEART methodology and the 4M Overturned Pyramid (MOP model, which are applied to assess marine accidents. Furthermore, the MOP model can effectively describe the relationships of other factors which affect the accidents; whereas, the HEART methodology is only focused on human factors.

How we learn to make decisions: rapid propagation of reinforcement learning prediction errors in humans.

Science.gov (United States)

Krigolson, Olav E; Hassall, Cameron D; Handy, Todd C

2014-03-01

Our ability to make decisions is predicated upon our knowledge of the outcomes of the actions available to us. Reinforcement learning theory posits that actions followed by a reward or punishment acquire value through the computation of prediction errors-discrepancies between the predicted and the actual reward. A multitude of neuroimaging studies have demonstrated that rewards and punishments evoke neural responses that appear to reflect reinforcement learning prediction errors [e.g., Krigolson, O. E., Pierce, L. J., Holroyd, C. B., & Tanaka, J. W. Learning to become an expert: Reinforcement learning and the acquisition of perceptual expertise. Journal of Cognitive Neuroscience, 21, 1833-1840, 2009; Bayer, H. M., & Glimcher, P. W. Midbrain dopamine neurons encode a quantitative reward prediction error signal. Neuron, 47, 129-141, 2005; O'Doherty, J. P. Reward representations and reward-related learning in the human brain: Insights from neuroimaging. Current Opinion in Neurobiology, 14, 769-776, 2004; Holroyd, C. B., & Coles, M. G. H. The neural basis of human error processing: Reinforcement learning, dopamine, and the error-related negativity. Psychological Review, 109, 679-709, 2002]. Here, we used the brain ERP technique to demonstrate that not only do rewards elicit a neural response akin to a prediction error but also that this signal rapidly diminished and propagated to the time of choice presentation with learning. Specifically, in a simple, learnable gambling task, we show that novel rewards elicited a feedback error-related negativity that rapidly decreased in amplitude with learning. Furthermore, we demonstrate the existence of a reward positivity at choice presentation, a previously unreported ERP component that has a similar timing and topography as the feedback error-related negativity that increased in amplitude with learning. The pattern of results we observed mirrored the output of a computational model that we implemented to compute reward

Representing cognitive activities and errors in HRA trees

International Nuclear Information System (INIS)

Gertman, D.I.

1992-01-01

This paper discusses development of a means by which to present cognitive information in human reliability assessment (HRA) event trees. The descriptions found in probabilistic risk assessments (PRAs) regarding the demands on, and the resulting performance of, nuclear power plant (NPP) crews often make use of the technique for human error rate prediction (THERP), which provides a mechanism, the HRA event tree, for presenting the analyst's conceptualization of the activities underlying performance and the errors associated with that performance. When using THERP, analysts have often omitted the more complex elements of human cognition from these trees. There has yet to be a concerted effort to take theory, principles, and data from cognitive psychology and wed it to the logic structure of the HRA event tree. This paper attempts to do so. The COGENT modeling scheme (cognitively based HRA event trees) adds two taxonomies to the HRA event tree proposed by Swain and Guttman. The first taxonomy, the one proposed by Norman and Reason, describes the type of error committed and implies something about the underlying cognition as well. The second of these, the Rasmussen taxonomy, provides description regarding the skill-based, rule-based, or knowledge-based behavior underlying the execution of tasks. It is not apparent and must be deduced from the pattern of errors exhibited by personnel

Impact of human error on lumber yield in rough mills

Science.gov (United States)

Urs Buehlmann; R. Edward Thomas; R. Edward Thomas

2002-01-01

Rough sawn, kiln-dried lumber contains characteristics such as knots and bark pockets that are considered by most people to be defects. When using boards to produce furniture components, these defects are removed to produce clear, defect-free parts. Currently, human operators identify and locate the unusable board areas containing defects. Errors in determining a...

Faces in places: humans and machines make similar face detection errors.

Directory of Open Access Journals (Sweden)

Bernard Marius 't Hart

Full Text Available The human visual system seems to be particularly efficient at detecting faces. This efficiency sometimes comes at the cost of wrongfully seeing faces in arbitrary patterns, including famous examples such as a rock configuration on Mars or a toast's roast patterns. In machine vision, face detection has made considerable progress and has become a standard feature of many digital cameras. The arguably most wide-spread algorithm for such applications ("Viola-Jones" algorithm achieves high detection rates at high computational efficiency. To what extent do the patterns that the algorithm mistakenly classifies as faces also fool humans? We selected three kinds of stimuli from real-life, first-person perspective movies based on the algorithm's output: correct detections ("real faces", false positives ("illusory faces" and correctly rejected locations ("non faces". Observers were shown pairs of these for 20 ms and had to direct their gaze to the location of the face. We found that illusory faces were mistaken for faces more frequently than non faces. In addition, rotation of the real face yielded more errors, while rotation of the illusory face yielded fewer errors. Using colored stimuli increases overall performance, but does not change the pattern of results. When replacing the eye movement by a manual response, however, the preference for illusory faces over non faces disappeared. Taken together, our data show that humans make similar face-detection errors as the Viola-Jones algorithm, when directing their gaze to briefly presented stimuli. In particular, the relative spatial arrangement of oriented filters seems of relevance. This suggests that efficient face detection in humans is likely to be pre-attentive and based on rather simple features as those encoded in the early visual system.

Action errors, error management, and learning in organizations.

Science.gov (United States)

Frese, Michael; Keith, Nina

2015-01-03

Every organization is confronted with errors. Most errors are corrected easily, but some may lead to negative consequences. Organizations often focus on error prevention as a single strategy for dealing with errors. Our review suggests that error prevention needs to be supplemented by error management--an approach directed at effectively dealing with errors after they have occurred, with the goal of minimizing negative and maximizing positive error consequences (examples of the latter are learning and innovations). After defining errors and related concepts, we review research on error-related processes affected by error management (error detection, damage control). Empirical evidence on positive effects of error management in individuals and organizations is then discussed, along with emotional, motivational, cognitive, and behavioral pathways of these effects. Learning from errors is central, but like other positive consequences, learning occurs under certain circumstances--one being the development of a mind-set of acceptance of human error.

Error management process for power stations

International Nuclear Information System (INIS)

Hirotsu, Yuko; Takeda, Daisuke; Fujimoto, Junzo; Nagasaka, Akihiko

2016-01-01

The purpose of this study is to establish 'error management process for power stations' for systematizing activities for human error prevention and for festering continuous improvement of these activities. The following are proposed by deriving concepts concerning error management process from existing knowledge and realizing them through application and evaluation of their effectiveness at a power station: an entire picture of error management process that facilitate four functions requisite for maraging human error prevention effectively (1. systematizing human error prevention tools, 2. identifying problems based on incident reports and taking corrective actions, 3. identifying good practices and potential problems for taking proactive measures, 4. prioritizeng human error prevention tools based on identified problems); detail steps for each activity (i.e. developing an annual plan for human error prevention, reporting and analyzing incidents and near misses) based on a model of human error causation; procedures and example of items for identifying gaps between current and desired levels of executions and outputs of each activity; stages for introducing and establishing the above proposed error management process into a power station. By giving shape to above proposals at a power station, systematization and continuous improvement of activities for human error prevention in line with the actual situation of the power station can be expected. (author)

Human Error Prediction and Countermeasures based on CREAM in Loading and Storage Phase of Spent Nuclear Fuel (SNF)

International Nuclear Information System (INIS)

Kim, Jae San; Kim, Min Su; Jo, Seong Youn

2007-01-01

With the steady demands for nuclear power energy in Korea, the amount of accumulated SNF has inevitably increased year by year. Thus far, SNF has been on-site transported from one unit to a nearby unit or an on-site dry storage facility. In the near future, as the amount of SNF generated approaches the capacity of these facilities, a percentage of it will be transported to another SNF storage facility. In the process of transporting SNF, human interactions involve inspecting and preparing the cask and spent fuel, loading the cask, transferring the cask and storage or monitoring the cask, etc. So, human actions play a significant role in SNF transportation. In analyzing incidents that have occurred during transport operations, several recent studies have indicated that 'human error' is a primary cause. Therefore, the objectives of this study are to predict and identify possible human errors during the loading and storage of SNF. Furthermore, after evaluating human error for each process, countermeasures to minimize human error are deduced

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.

Application of objective clinical human reliability analysis (OCHRA) in assessment of technical performance in laparoscopic rectal cancer surgery.

Science.gov (United States)

Foster, J D; Miskovic, D; Allison, A S; Conti, J A; Ockrim, J; Cooper, E J; Hanna, G B; Francis, N K

2016-06-01

Laparoscopic rectal resection is technically challenging, with outcomes dependent upon technical performance. No robust objective assessment tool exists for laparoscopic rectal resection surgery. This study aimed to investigate the application of the objective clinical human reliability analysis (OCHRA) technique for assessing technical performance of laparoscopic rectal surgery and explore the validity and reliability of this technique. Laparoscopic rectal cancer resection operations were described in the format of a hierarchical task analysis. Potential technical errors were defined. The OCHRA technique was used to identify technical errors enacted in videos of twenty consecutive laparoscopic rectal cancer resection operations from a single site. The procedural task, spatial location, and circumstances of all identified errors were logged. Clinical validity was assessed through correlation with clinical outcomes; reliability was assessed by test-retest. A total of 335 execution errors identified, with a median 15 per operation. More errors were observed during pelvic tasks compared with abdominal tasks (p technical performance of laparoscopic rectal surgery.

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

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 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.

Multicenter Assessment of Gram Stain Error Rates.

Science.gov (United States)

Samuel, Linoj P; Balada-Llasat, Joan-Miquel; Harrington, Amanda; Cavagnolo, Robert

2016-06-01

Gram stains remain the cornerstone of diagnostic testing in the microbiology laboratory for the guidance of empirical treatment prior to availability of culture results. Incorrectly interpreted Gram stains may adversely impact patient care, and yet there are no comprehensive studies that have evaluated the reliability of the technique and there are no established standards for performance. In this study, clinical microbiology laboratories at four major tertiary medical care centers evaluated Gram stain error rates across all nonblood specimen types by using standardized criteria. The study focused on several factors that primarily contribute to errors in the process, including poor specimen quality, smear preparation, and interpretation of the smears. The number of specimens during the evaluation period ranged from 976 to 1,864 specimens per site, and there were a total of 6,115 specimens. Gram stain results were discrepant from culture for 5% of all specimens. Fifty-eight percent of discrepant results were specimens with no organisms reported on Gram stain but significant growth on culture, while 42% of discrepant results had reported organisms on Gram stain that were not recovered in culture. Upon review of available slides, 24% (63/263) of discrepant results were due to reader error, which varied significantly based on site (9% to 45%). The Gram stain error rate also varied between sites, ranging from 0.4% to 2.7%. The data demonstrate a significant variability between laboratories in Gram stain performance and affirm the need for ongoing quality assessment by laboratories. Standardized monitoring of Gram stains is an essential quality control tool for laboratories and is necessary for the establishment of a quality benchmark across laboratories. Copyright © 2016, American Society for Microbiology. All Rights Reserved.

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

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

Scaling prediction errors to reward variability benefits error-driven learning in humans.

Science.gov (United States)

Diederen, Kelly M J; Schultz, Wolfram

2015-09-01

Effective error-driven learning requires individuals to adapt learning to environmental reward variability. The adaptive mechanism may involve decays in learning rate across subsequent trials, as shown previously, and rescaling of reward prediction errors. The present study investigated the influence of prediction error scaling and, in particular, the consequences for learning performance. Participants explicitly predicted reward magnitudes that were drawn from different probability distributions with specific standard deviations. By fitting the data with reinforcement learning models, we found scaling of prediction errors, in addition to the learning rate decay shown previously. Importantly, the prediction error scaling was closely related to learning performance, defined as accuracy in predicting the mean of reward distributions, across individual participants. In addition, participants who scaled prediction errors relative to standard deviation also presented with more similar performance for different standard deviations, indicating that increases in standard deviation did not substantially decrease "adapters'" accuracy in predicting the means of reward distributions. However, exaggerated scaling beyond the standard deviation resulted in impaired performance. Thus efficient adaptation makes learning more robust to changing variability. Copyright © 2015 the American Physiological Society.

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)

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)

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

Plant specification of a generic human-error data through a two-stage Bayesian approach

International Nuclear Information System (INIS)

Heising, C.D.; Patterson, E.I.

1984-01-01

Expert judgement concerning human performance in nuclear power plants is quantitatively coupled with actuarial data on such performance in order to derive plant-specific human-error rate probability distributions. The coupling procedure consists of a two-stage application of Bayes' theorem to information which is grouped by type. The first information type contains expert judgement concerning human performance at nuclear power plants in general. Data collected on human performance at a group of similar plants forms the second information type. The third information type consists of data on human performance in a specific plant which has the same characteristics as the group members. The first and second information types are coupled in the first application of Bayes' theorem to derive a probability distribution for population performance. This distribution is then combined with the third information type in a second application of Bayes' theorem to determine a plant-specific human-error rate probability distribution. The two stage Bayesian procedure thus provides a means to quantitatively couple sparse data with expert judgement in order to obtain a human performance probability distribution based upon available information. Example calculations for a group of like reactors are also given. (author)

Taking human error into account in the design of nuclear reactor centres

International Nuclear Information System (INIS)

Prouillac; Lerat; Janoir.

1982-05-01

The role of the operator in the centralized management of pressurized water reactors is studied. Different types of human error likely to arise, the means of their prevention and methods of mitigating their consequences are presented. Some possible improvements are outlined

The application of human error prevention tool in Tianwan nuclear power station

International Nuclear Information System (INIS)

Qiao Zhiguo

2013-01-01

This paper mainly discusses the application and popularization of human error prevention tool in Tianwan nuclear power station, including the study on project implementation background, main contents and innovation, performance management, innovation practice and development, and performance of innovation application. (authors)

Modeling and Quantification of Team Performance in Human Reliability Analysis for Probabilistic Risk Assessment

Energy Technology Data Exchange (ETDEWEB)

Jeffrey C. JOe; Ronald L. Boring

2014-06-01

Probabilistic Risk Assessment (PRA) and Human Reliability Assessment (HRA) are important technical contributors to the United States (U.S.) Nuclear Regulatory Commission’s (NRC) risk-informed and performance based approach to regulating U.S. commercial nuclear activities. Furthermore, all currently operating commercial NPPs in the U.S. are required by federal regulation to be staffed with crews of operators. Yet, aspects of team performance are underspecified in most HRA methods that are widely used in the nuclear industry. There are a variety of "emergent" team cognition and teamwork errors (e.g., communication errors) that are 1) distinct from individual human errors, and 2) important to understand from a PRA perspective. The lack of robust models or quantification of team performance is an issue that affects the accuracy and validity of HRA methods and models, leading to significant uncertainty in estimating HEPs. This paper describes research that has the objective to model and quantify team dynamics and teamwork within NPP control room crews for risk informed applications, thereby improving the technical basis of HRA, which improves the risk-informed approach the NRC uses to regulate the U.S. commercial nuclear industry.

The error in total error reduction.

Science.gov (United States)

Witnauer, James E; Urcelay, Gonzalo P; Miller, Ralph R

2014-02-01

Most models of human and animal learning assume that learning is proportional to the discrepancy between a delivered outcome and the outcome predicted by all cues present during that trial (i.e., total error across a stimulus compound). This total error reduction (TER) view has been implemented in connectionist and artificial neural network models to describe the conditions under which weights between units change. Electrophysiological work has revealed that the activity of dopamine neurons is correlated with the total error signal in models of reward learning. Similar neural mechanisms presumably support fear conditioning, human contingency learning, and other types of learning. Using a computational modeling approach, we compared several TER models of associative learning to an alternative model that rejects the TER assumption in favor of local error reduction (LER), which assumes that learning about each cue is proportional to the discrepancy between the delivered outcome and the outcome predicted by that specific cue on that trial. The LER model provided a better fit to the reviewed data than the TER models. Given the superiority of the LER model with the present data sets, acceptance of TER should be tempered. Copyright © 2013 Elsevier Inc. All rights reserved.

Control of Human Error and comparison Level risk after correction action With the SHERPA Method in a control Room of petrochemical industry

Directory of Open Access Journals (Sweden)

A. Zakerian

2011-12-01

Full Text Available Background and aims Today in many jobs like nuclear, military and chemical industries, human errors may result in a disaster. Accident in different places of the world emphasizes this subject and we indicate for example, Chernobyl disaster in (1986, tree Mile accident in (1974 and Flixborough explosion in (1974.So human errors identification especially in important and intricate systems is necessary and unavoidable for predicting control methods.   Methods Recent research is a case study and performed in Zagross Methanol Company in Asalouye (South pars.   Walking –Talking through method with process expert and control room operators, inspecting technical documents are used for collecting required information and completing Systematic Human Error Reductive and Predictive Approach (SHERPA worksheets.   Results analyzing SHERPA worksheet indicated that, were accepting capable invertebrate errors % 71.25, % 26.75 undesirable errors, % 2 accepting capable(with change errors, % 0 accepting capable errors, and after correction action forecast Level risk to this arrangement, accepting capable invertebrate errors % 0, % 4.35 undesirable errors , % 58.55 accepting capable(with change errors, % 37.1 accepting capable errors .   ConclusionFinally this result is comprehension that this method in different industries especially in chemical industries is enforceable and useful for human errors identification that may lead to accident and adventures.

Detailed semantic analyses of human error incidents occurring at domestic nuclear power plants to fiscal year 2000

International Nuclear Information System (INIS)

Tsuge, Tadashi; Hirotsu, Yuko; Takano, Kenichi; Ebisu, Mitsuhiro; Tsumura, Joji

2003-01-01

Analysing and evaluating observed cases of human error incidents with the emphasis on human factors and behavior involved was essential for preventing recurrence of those. CRIEPI has been conducting detailed and structures analyses of all incidents reported during last 35 year based on J-HPES, from the beginning of the first Tokai nuclear power operation till fiscal year of 2000, in which total 212 human error cases are identified. Results obtained by the analyses have been stored into the J-HPES data-base. This summarized the semantic analyses on all case-studies stored in the above data-base to grasp the practical and concrete contents and trend of more frequently observed human errors (as are called trigger actions here), causal factors and preventive measures. These semantic analyses have been executed by classifying all those items into some categories that could be considered as having almost the same meaning using the KJ method. Followings are obtained typical results by above analyses: (1) Trigger action-Those could be classified into categories of operation or categories of maintenance. Operational timing errors' and 'operational quantitative errors' were major actions in trigger actions of operation, those occupied about 20% among all actions. At trigger actions of maintenance, 'maintenance quantitative error' were major actions, those occupied quarter among all actions; (2) Causal factor- 'Human internal status' were major factors, as in concrete factors, those occupied 'improper persistence' and 'lack of knowledge'; (3) Preventive measure-Most frequent measures got were job management changes in procedural software improvements, which was from 70% to 80%. As for preventive measures of operation, software improvements have been implemented on 'organization and work practices' and 'individual consciousness'. Concerning preventive measures of maintenance, improvements have been implemented on 'organization and work practices'. (author)

Quality assurance of human error modelling in a major probabilistic risk assessment programme

International Nuclear Information System (INIS)

Rycraft, H.S.

1990-01-01

A method of incorporating the consideration of operator error within a major PRA exercise is described along with the quality assurance procedures employed to ensure a quality product. The exercise was undertaken at the Sellafield Reprocessing Plant. (author)

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...

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

Determining The Factors Causing Human Error Deficiencies At A Public Utility Company

Directory of Open Access Journals (Sweden)

F. W. Badenhorst

2004-11-01

Full Text Available According to Neff (1977, as cited by Bergh (1995, the westernised culture considers work important for industrial mental health. Most individuals experience work positively, which creates a positive attitude. Should this positive attitude be inhibited, workers could lose concentration and become bored, potentially resulting in some form of human error. The aim of this research was to determine the factors responsible for human error events, which lead to power supply failures at Eskom power stations. Proposals were made for the reduction of these contributing factors towards improving plant performance. The target population was 700 panel operators in Eskom’s Power Generation Group. The results showed that factors leading to human error can be reduced or even eliminated. Opsomming Neff (1977 soos aangehaal deur Bergh (1995, skryf dat in die westerse kultuur werk belangrik vir bedryfsgeestesgesondheid is. Die meeste persone ervaar werk as positief, wat ’n positiewe gesindheid kweek. Indien hierdie positiewe gesindheid geïnhibeer word, kan dit lei tot ’n gebrek aan konsentrasie by die werkers. Werkers kan verveeld raak en dit kan weer lei tot menslike foute. Die doel van hierdie navorsing is om die faktore vas te stel wat tot menslike foute lei, en wat bydra tot onderbrekings in kragvoorsiening by Eskom kragstasies. Voorstelle is gemaak vir die vermindering van hierdie bydraende faktore ten einde die kragaanleg se prestasie te verbeter. Die teiken-populasie was 700 paneel-operateurs in die Kragopwekkingsgroep by Eskom. Die resultate dui daarop dat die faktore wat aanleiding gee tot menslike foute wel verminder, of geëlimineer kan word.

A Model-based Framework for Risk Assessment in Human-Computer Controlled Systems

Science.gov (United States)

Hatanaka, Iwao

2000-01-01

The rapid growth of computer technology and innovation has played a significant role in the rise of computer automation of human tasks in modem production systems across all industries. Although the rationale for automation has been to eliminate "human error" or to relieve humans from manual repetitive tasks, various computer-related hazards and accidents have emerged as a direct result of increased system complexity attributed to computer automation. The risk assessment techniques utilized for electromechanical systems are not suitable for today's software-intensive systems or complex human-computer controlled systems. This thesis will propose a new systemic model-based framework for analyzing risk in safety-critical systems where both computers and humans are controlling safety-critical functions. A new systems accident model will be developed based upon modem systems theory and human cognitive processes to better characterize system accidents, the role of human operators, and the influence of software in its direct control of significant system functions. Better risk assessments will then be achievable through the application of this new framework to complex human-computer controlled systems.

A classification scheme of erroneous behaviors for human error probability estimations based on simulator data

International Nuclear Information System (INIS)

Kim, Yochan; Park, Jinkyun; Jung, Wondea

2017-01-01

Because it has been indicated that empirical data supporting the estimates used in human reliability analysis (HRA) is insufficient, several databases have been constructed recently. To generate quantitative estimates from human reliability data, it is important to appropriately sort the erroneous behaviors found in the reliability data. Therefore, this paper proposes a scheme to classify the erroneous behaviors identified by the HuREX (Human Reliability data Extraction) framework through a review of the relevant literature. A case study of the human error probability (HEP) calculations is conducted to verify that the proposed scheme can be successfully implemented for the categorization of the erroneous behaviors and to assess whether the scheme is useful for the HEP quantification purposes. Although continuously accumulating and analyzing simulator data is desirable to secure more reliable HEPs, the resulting HEPs were insightful in several important ways with regard to human reliability in off-normal conditions. From the findings of the literature review and the case study, the potential and limitations of the proposed method are discussed. - Highlights: • A taxonomy of erroneous behaviors is proposed to estimate HEPs from a database. • The cognitive models, procedures, HRA methods, and HRA databases were reviewed. • HEPs for several types of erroneous behaviors are calculated as a case study.

Errors and violations

International Nuclear Information System (INIS)

Reason, J.

1988-01-01

This paper is in three parts. The first part summarizes the human failures responsible for the Chernobyl disaster and argues that, in considering the human contribution to power plant emergencies, it is necessary to distinguish between: errors and violations; and active and latent failures. The second part presents empirical evidence, drawn from driver behavior, which suggest that errors and violations have different psychological origins. The concluding part outlines a resident pathogen view of accident causation, and seeks to identify the various system pathways along which errors and violations may be propagated

Assessing energy forecasting inaccuracy by simultaneously considering temporal and absolute errors

International Nuclear Information System (INIS)

Frías-Paredes, Laura; Mallor, Fermín; Gastón-Romeo, Martín; León, Teresa

2017-01-01

Highlights: • A new method to match time series is defined to assess energy forecasting accuracy. • This method relies in a new family of step patterns that optimizes the MAE. • A new definition of the Temporal Distortion Index between two series is provided. • A parametric extension controls both the temporal distortion index and the MAE. • Pareto optimal transformations of the forecast series are obtained for both indexes. - Abstract: Recent years have seen a growing trend in wind and solar energy generation globally and it is expected that an important percentage of total energy production comes from these energy sources. However, they present inherent variability that implies fluctuations in energy generation that are difficult to forecast. Thus, forecasting errors have a considerable role in the impacts and costs of renewable energy integration, management, and commercialization. This study presents an important advance in the task of analyzing prediction models, in particular, in the timing component of prediction error, which improves previous pioneering results. A new method to match time series is defined in order to assess energy forecasting accuracy. This method relies on a new family of step patterns, an essential component of the algorithm to evaluate the temporal distortion index (TDI). This family minimizes the mean absolute error (MAE) of the transformation with respect to the reference series (the real energy series) and also allows detailed control of the temporal distortion entailed in the prediction series. The simultaneous consideration of temporal and absolute errors allows the use of Pareto frontiers as characteristic error curves. Real examples of wind energy forecasts are used to illustrate the results.

Team errors: definition and taxonomy