WorldWideScience

Sample records for human errors leading

  1. Human errors and mistakes

    International Nuclear Information System (INIS)

    Wahlstroem, B.

    1993-01-01

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

  2. Common ECG Lead Placement Errors. Part I: Limb Lead Reversals

    Directory of Open Access Journals (Sweden)

    Allison V. Rosen

    2015-10-01

    Full Text Available Background: Electrocardiography (ECG is a very useful diagnostic tool. However, errors in placement of ECG leads can create artifacts, mimic pathologies, and hinder proper ECG interpretation. It is important for members of the health care team to be able to recognize the common patterns resulting from lead placement errors. Methods: 12-lead ECGs were recorded in a single male healthy subject in his mid 20s. Six different limb lead reversals were compared to ECG recordings from correct lead placement. Results: Classic ECG patterns were observed when leads were reversed. Methods of discriminating these ECG patterns from true pathologic findings were described. Conclusion: Correct recording and interpretation of ECGs is key to providing optimal patient care. It is therefore crucial to be able to recognize common ECG patterns that are indicative of lead reversals.

  3. 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...

  4. 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.

  5. 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

  6. 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

  7. 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.

  8. 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

  9. 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....

  10. 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.

  11. 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

  12. 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

  13. 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.

  14. Collection of offshore human error probability data

    International Nuclear Information System (INIS)

    Basra, Gurpreet; Kirwan, Barry

    1998-01-01

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

  15. 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...

  16. 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.)

  17. 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)

  18. 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)

  19. 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)

  20. 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

  1. 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)

  2. 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

  3. Learning from error: leading a culture of safety.

    Science.gov (United States)

    Gibson, Russell; Armstrong, Alexander; Till, Alex; McKimm, Judy

    2017-07-02

    A recent shift towards more collective leadership in the NHS can help to achieve a culture of safety, particularly through encouraging frontline staff to participate and take responsibility for improving safety through learning from error and near misses. Leaders must ensure that they provide psychological safety, organizational fairness and learning systems for staff to feel confident in raising concerns, that they have the autonomy and skills to lead continual improvement, and that they have responsibility for spreading this learning within and across organizations.

  4. 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

  5. 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

  6. 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.

  7. A chance to avoid mistakes human error

    International Nuclear Information System (INIS)

    Amaro, Pablo; Obeso, Eduardo; Gomez, Ruben

    2010-01-01

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

  8. Simulator data on human error probabilities

    International Nuclear Information System (INIS)

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

    1982-01-01

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

  9. 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

  10. 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)

  11. 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)

  12. 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)

  13. Eponyms in medical sciences: historical errors that lead to injustice

    Directory of Open Access Journals (Sweden)

    Jorge Eduardo Duque-Parra

    2018-01-01

    Full Text Available Introduction: Throughout history, eponyms have been used in medical sciences to designate anatomical structures although they do not provide any descriptive or functional information, which is equivalent to a mistake in the light of current thinking. Double and triple eponyms have been used to name the same structure, thus creating confusion that leads to believe that a discovery or description was made by several persons at the same time. Although eponyms have been abolished from anatomical terminology for over eight decades and still generate problems in communication and in the teachinglearning process, medical sciences professionals continue to use them. Objective: To analyze some examples of arbitrary assignment of eponyms in morphology that have led to historical errors and perpetuated them. Conclusion: Granting an eponym to an anatomical structure may not reflect the truth about the person who discovered it and may obey to arbitrary factors that induce possible historical errors and injustice. In addition, using them hinders communication between health professionals, as well as the teaching-learning process.

  14. Human Error Assessmentin Minefield Cleaning Operation Using Human Event Analysis

    Directory of Open Access Journals (Sweden)

    Mohammad Hajiakbari

    2015-12-01

    Full Text Available Background & objective: Human error is one of the main causes of accidents. Due to the unreliability of the human element and the high-risk nature of demining operations, this study aimed to assess and manage human errors likely to occur in such operations. Methods: This study was performed at a demining site in war zones located in the West of Iran. After acquiring an initial familiarity with the operations, methods, and tools of clearing minefields, job task related to clearing landmines were specified. Next, these tasks were studied using HTA and related possible errors were assessed using ATHEANA. Results: de-mining task was composed of four main operations, including primary detection, technical identification, investigation, and neutralization. There were found four main reasons for accidents occurring in such operations; walking on the mines, leaving mines with no action, error in neutralizing operation and environmental explosion. The possibility of human error in mine clearance operations was calculated as 0.010. Conclusion: The main causes of human error in de-mining operations can be attributed to various factors such as poor weather and operating conditions like outdoor work, inappropriate personal protective equipment, personality characteristics, insufficient accuracy in the work, and insufficient time available. To reduce the probability of human error in de-mining operations, the aforementioned factors should be managed properly.

  15. 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

  16. Applications of human error analysis to aviation and space operations

    International Nuclear Information System (INIS)

    Nelson, W.R.

    1998-01-01

    For the past several years at the Idaho National Engineering and Environmental Laboratory (INEEL) we have been working to apply methods of human error analysis to the design of complex systems. We have focused on adapting human reliability analysis (HRA) methods that were developed for Probabilistic Safety Assessment (PSA) for application to system design. We are developing methods so that human errors can be systematically identified during system design, the potential consequences of each error can be assessed, and potential corrective actions (e.g. changes to system design or procedures) can be identified. These applications lead to different requirements when compared with HR.As performed as part of a PSA. For example, because the analysis will begin early during the design stage, the methods must be usable when only partial design information is available. In addition, the ability to perform numerous ''what if'' analyses to identify and compare multiple design alternatives is essential. Finally, since the goals of such human error analyses focus on proactive design changes rather than the estimate of failure probabilities for PRA, there is more emphasis on qualitative evaluations of error relationships and causal factors than on quantitative estimates of error frequency. The primary vehicle we have used to develop and apply these methods has been a series of prqjects sponsored by the National Aeronautics and Space Administration (NASA) to apply human error analysis to aviation operations. The first NASA-sponsored project had the goal to evaluate human errors caused by advanced cockpit automation. Our next aviation project focused on the development of methods and tools to apply human error analysis to the design of commercial aircraft. This project was performed by a consortium comprised of INEEL, NASA, and Boeing Commercial Airplane Group. The focus of the project was aircraft design and procedures that could lead to human errors during airplane maintenance

  17. 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.

  18. 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

  19. 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.

  20. 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)

  1. 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

  2. THERP and HEART integrated methodology for human error assessment

    Science.gov (United States)

    Castiglia, Francesco; Giardina, Mariarosa; Tomarchio, Elio

    2015-11-01

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

  3. 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.

  4. 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.

  5. Human errors, countermeasures for their prevention and evaluation

    International Nuclear Information System (INIS)

    Kohda, Takehisa; Inoue, Koichi

    1992-01-01

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

  6. 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.

  7. 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

  8. 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

  9. Understanding Human Error in Naval Aviation Mishaps.

    Science.gov (United States)

    Miranda, Andrew T

    2018-04-01

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

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

    National Research Council Canada - National Science Library

    Wood, Brian

    2000-01-01

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

  11. 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.

  12. Eponyms in medical sciences: historical errors that lead to injustice

    OpenAIRE

    Jorge Eduardo Duque-Parra; John Barco-Ríos; Natalia Dávila-Alzate

    2018-01-01

    Introduction: Throughout history, eponyms have been used in medical sciences to designate anatomical structures although they do not provide any descriptive or functional information, which is equivalent to a mistake in the light of current thinking. Double and triple eponyms have been used to name the same structure, thus creating confusion that leads to believe that a discovery or description was made by several persons at the same time. Although eponyms have been abolished from anatomical ...

  13. 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

  14. Influence of organizational culture on human error

    International Nuclear Information System (INIS)

    Friedlander, M.A.; Evans, S.A.

    1996-01-01

    Much has been written in contemporary business literature during the last decade describing the role that corporate culture plays in virtually every aspect of a firm's success. In 1990 Kotter and Heskett wrote, open-quotes We found that firms with cultures that emphasized all of the key managerial constituencies (customers, stockholders, and employees) and leadership from managers at all levels out-performed firms that did not have those cultural traits by a huge margin. Over an eleven year period, the former increased revenues by an average of 682 percent versus 166 percent for the latter, expanded their workforce by 282 percent versus 36 percent, grew their stock prices by 901 percent versus 74 percent, and improved their net incomes by 756 percent versus 1 percent.close quotes Since the mid-1980s, several electric utilities have documented their efforts to undertake strategic culture change. In almost every case, these efforts have yielded dramatic improvements in the open-quotes bottom-lineclose quotes operational and financial results (e.g., Western Resources, Arizona Public Service, San Diego Gas ampersand Electric, and Electricity Trust of South Australia). Given the body of evidence that indicates a relationship between high-performing organizational culture and the financial and business success of a firm, Pennsylvania Power ampersand Light Company undertook a study to identify the relationship between organizational culture and the frequency, severity, and nature of human error at the Susquehanna Steam Electric Station. The underlying proposition for this asssessment is that organizational culture is an independent variable that transforms external events into organizational performance

  15. 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

  16. 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.

  17. 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.

  18. 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

  19. 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...

  20. 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

  1. Minimizing driver errors: examining factors leading to failed target tracking and detection.

    Science.gov (United States)

    2013-06-01

    Driving a motor vehicle is a common practice for many individuals. Although driving becomes : repetitive and a very habitual task, errors can occur that lead to accidents. One factor that can be a : cause for such errors is a lapse in attention or a ...

  2. Cascade of neural events leading from error commission to subsequent awareness revealed using EEG source imaging.

    Directory of Open Access Journals (Sweden)

    Monica Dhar

    Full Text Available The goal of the present study was to shed light on the respective contributions of three important action monitoring brain regions (i.e. cingulate cortex, insula, and orbitofrontal cortex during the conscious detection of response errors. To this end, fourteen healthy adults performed a speeded Go/Nogo task comprising Nogo trials of varying levels of difficulty, designed to elicit aware and unaware errors. Error awareness was indicated by participants with a second key press after the target key press. Meanwhile, electromyogram (EMG from the response hand was recorded in addition to high-density scalp electroencephalogram (EEG. In the EMG-locked grand averages, aware errors clearly elicited an error-related negativity (ERN reflecting error detection, and a later error positivity (Pe reflecting conscious error awareness. However, no Pe was recorded after unaware errors or hits. These results are in line with previous studies suggesting that error awareness is associated with generation of the Pe. Source localisation results confirmed that the posterior cingulate motor area was the main generator of the ERN. However, inverse solution results also point to the involvement of the left posterior insula during the time interval of the Pe, and hence error awareness. Moreover, consecutive to this insular activity, the right orbitofrontal cortex (OFC was activated in response to aware and unaware errors but not in response to hits, consistent with the implication of this area in the evaluation of the value of an error. These results reveal a precise sequence of activations in these three non-overlapping brain regions following error commission, enabling a progressive differentiation between aware and unaware errors as a function of time elapsed, thanks to the involvement first of interoceptive or proprioceptive processes (left insula, later leading to the detection of a breach in the prepotent response mode (right OFC.

  3. Sensitivity of risk parameters to human errors for a PWR

    International Nuclear Information System (INIS)

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

    1980-01-01

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

  4. 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

  5. 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

  6. 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.

  7. 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.

  8. 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."

  9. 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

  10. Inherent safety, ethics and human error.

    Science.gov (United States)

    Papadaki, Maria

    2008-02-11

    stated. The reason this article is presented here is that I believe that often, complex accidents, similarly to insignificant ones, often demonstrate an attitude which can be characterized as "inherently unsafe". I take the view that the enormous human potential and the human ability to minimize accidents needs to become a focal point towards inherent safety. Restricting ourselves to human limitations and how we could "treat" or prevent humans from not making accidents needs to be re-addressed. The purpose of this presentation is to highlight observations and provoke a discussion on how we could possibly improve the understanding of safety related issues. I do not intent to reject or criticize existing methodologies. (The entire presentation is strongly influenced by Trevor Kletz's work although our views are often different.).

  11. Human Error Probability Assessment During Maintenance Activities of Marine Systems

    Directory of Open Access Journals (Sweden)

    Rabiul Islam

    2018-03-01

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

  12. Radioactive lead studies in the human

    International Nuclear Information System (INIS)

    Blake, K.C.H.

    1980-08-01

    The differing susceptibility of individuals to the toxic effects of chronic lead exposure has never been fully understood. As the major intake of lead in the human is from food and beverages, any variation between individuals of the quantity of lead absorbed from the gut, and of the distribution and excretion of this lead, may account for the differences in individual susceptibility. The food and beverages themselves may have an influence, and to investigate their effects on absorption, distribution and excretion of lead, experiments were performed on normal subjects using a short lived radionuclide of lead, 203 Pb, and instruments generally available in Nuclear Medicine. Lead absorption between different individuals showed a wide variation when 203 Pb was taken as a single dose between meals. Minerals were found to be mainly responsible for affecting absorption when one subject ingested 203 Pb in control meals from which one dietary constituent at a time was omitted. Calcium and phosphorous were found to reduce the absorption of 203 Pb to approximately the same level as that produced by the total minerals. Calcium reduced absorption more than phosphorous when these minerals were ingested separately with 203 Pb. It was concluded that the calcium and phosphorous in the diet could influence susceptibility to lead toxicity through changes in the absorption of food and water lead and in the distribution of lead in the body. The results suggest that the prophylactic effect of calcium on lead absorption should be recognised and applied in this time of increased environmental levels of lead

  13. Technique for human-error sequence identification and signification

    International Nuclear Information System (INIS)

    Heslinga, G.

    1988-01-01

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

  14. 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

  15. 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

  16. 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,

  17. 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,

  18. 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.

  19. 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...

  20. 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 ...

  1. Some aspects of statistical modeling of human-error probability

    International Nuclear Information System (INIS)

    Prairie, R.R.

    1982-01-01

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

  2. 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.

  3. 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.

  4. 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

  5. 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)

  6. 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.)

  7. 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.)

  8. 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.

  9. 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)

  10. A critique of recent models for human error rate assessment

    International Nuclear Information System (INIS)

    Apostolakis, G.E.

    1988-01-01

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

  11. Attentional capture by irrelevant transients leads to perceptual errors in a competitive change detection task

    Directory of Open Access Journals (Sweden)

    Daniel eSchneider

    2012-05-01

    Full Text Available Theories on visual change detection imply that attention is a necessary but not sufficient prerequisite for aware perception. Misguidance of attention due to salient irrelevant distractors can therefore lead to severe deficits in change detection. The present study investigates the mechanisms behind such perceptual errors and their relation to error processing on higher cognitive levels. Participants had to detect a luminance change that occasionally occurred simultaneously with an irrelevant orientation change in the opposite hemi-field (conflict condition. By analyzing event-related potentials in the EEG separately in those error prone conflict trials for correct and erroneous change detection, we demonstrate that only correct change detection was associated with the allocation of attention to the relevant luminance change. Erroneous change detection was associated with an initial capture of attention towards the irrelevant orientation change in the N1 time window and a lack of subsequent target selection processes (N2pc. Errors were additionally accompanied by an increase of the fronto-central N2 and a kind of error negativity (Ne or ERN, which, however, peaked prior to the response. These results suggest that a strong perceptual conflict by salient distractors can disrupt the further processing of relevant information and thus affect its aware perception. Yet, it does not impair higher cognitive processes for conflict and error detection, indicating that these processes are independent from awareness.

  12. 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)

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

    National Research Council Canada - National Science Library

    Boex, Anthony

    2001-01-01

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

  14. 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

  15. 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

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

    African Journals Online (AJOL)

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

  17. 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...

  18. 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 ...

  19. 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...

  20. 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

  1. Mitigating voltage lead errors of an AC Josephson voltage standard by impedance matching

    Science.gov (United States)

    Zhao, Dongsheng; van den Brom, Helko E.; Houtzager, Ernest

    2017-09-01

    A pulse-driven AC Josephson voltage standard (ACJVS) generates calculable AC voltage signals at low temperatures, whereas measurements are performed with a device under test (DUT) at room temperature. The voltage leads cause the output voltage to show deviations that scale with the frequency squared. Error correction mechanisms investigated so far allow the ACJVS to be operational for frequencies up to 100 kHz. In this paper, calculations are presented to deal with these errors in terms of reflected waves. Impedance matching at the source side of the system, which is loaded with a high-impedance DUT, is proposed as an accurate method to mitigate these errors for frequencies up to 1 MHz. Simulations show that the influence of non-ideal component characteristics, such as the tolerance of the matching resistor, the capacitance of the load input impedance, losses in the voltage leads, non-homogeneity in the voltage leads, a non-ideal on-chip connection and inductors between the Josephson junction array and the voltage leads, can be corrected for using the proposed procedures. The results show that an expanded uncertainty of 12 parts in 106 (k  =  2) at 1 MHz and 0.5 part in 106 (k  =  2) at 100 kHz is within reach.

  2. 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

  3. 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

  4. 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)

  5. Self-assessment of human performance errors in nuclear operations

    International Nuclear Information System (INIS)

    Chambliss, K.V.

    1996-01-01

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

  6. 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)

  7. 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

  8. 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.)

  9. 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)

  10. 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...

  11. 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

  12. 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.

  13. 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

  14. 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)

  15. 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)

  16. 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

    -measures analysis of variance. Results: The thresholds of detectability averaged over all observers were approximately 2.5 mm for in-plane translations, 1.6 deg. for in-plane rotations, 1 deg. for out-of-plane rotations, and 8% change in magnification for out-of-plane translations along the central axis. When one inexperienced observer is excluded, the average threshold for change in magnification is 5%. Experienced observers tended to perform better, but differences between groups were not statistically significant. Thresholds were computed as averages over all observers. Because of the broad range of observer capabilities, some detection tasks were too difficult for some observers, leading to missing threshold values in our data analysis. The missing values were excluded from computation of the average thresholds reported above. The effect of the missing values is to bias the average values toward the best human performance. Conclusions: Under favorable conditions, humans can detect small errors in setup geometry. The thresholds for error detection reported in this study are believed to represent rigorous but reasonable benchmarks that can be incorporated into studies evaluating algorithms for computer-assisted detection of setup errors in electronic portal images

  17. 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)

  18. Human error probability quantification using fuzzy methodology in nuclear plants

    International Nuclear Information System (INIS)

    Nascimento, Claudio Souza do

    2010-01-01

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

  19. 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

  20. 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

  1. 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.

  2. 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.

  3. 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

  4. In vivo x-ray fluorescence of bone lead in the study of human lead metabolism: Serum lead, whole blood lead, bone lead, and cumulative exposure

    International Nuclear Information System (INIS)

    Cake, K.M.; Chettle, D.R.; Webber, C.E.; Gordon, C.L.

    1995-01-01

    Traditionally, clinical studies of lead's effect on health have relied on blood lead levels to indicate lead exposure. However, this is unsatisfactory because blood lead levels have a half-life of approximately 5 weeks, and thus reflect recent exposure. Over 90% of the lead body burden is in bone, and it is thought to have a long residence time, thus implying that measurements of bone lead reflect cumulative exposure. So, measurements of bone lead are useful in understanding the long-term health effects of lead. Ahlgren reported the first noninvasive measurements of bone lead in humans, where γ-rays from 57 Co were used to excite the K series x-rays of lead. The lead detection system at McMaster University uses a 109 Cd source which is positioned at the center of the detector face (HPGe) and a near backscatter (∼160 degrees) geometry. This arrangement allows great flexibility, since one can sample lead in a range of different bone sites due to a robust normalization technique which eliminates the need to correct for bone geometry, thickness of overlying tissue, and other related factors. The effective radiation dose to an adult during an x-ray fluorescence bone lead measurement is extremely low, being 35 nSv. This paper addresses the issue of how bone, whole blood, and serum lead concentrations can be related in order to understand a person's lead exposure history

  5. 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

  6. 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

  7. 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.

  8. Soil is an important pathway of human lead exposure.

    OpenAIRE

    Mielke, H W; Reagan, P L

    1998-01-01

    This review shows the equal or greater importance of leaded gasoline-contaminated dust compared to lead-based paint to the child lead problem, and that soil lead, resulting from leaded gasoline and pulverized lead-based paint, is at least or more important than lead-based paint (intact and not pulverized) as a pathway of human lead exposure. Because lead-based paint is a high-dose source, the biologically relevant dosage is similar to lead in soil. Both lead-based paint and soil lead are asso...

  9. 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)

  10. Lead sources in human diet in Greenland

    DEFF Research Database (Denmark)

    Bjerregaard, Peter; Johansen, Poul; Mulvad, Gert

    2004-01-01

    Although blood lead levels have declined in Greenland, they are still elevated despite the fact that lead levels in the Greenland environment are very low. Fragments of lead shot in game birds have been suggested as an important source of dietary exposure, and meals of sea birds, particularly eider......, contain high concentrations of lead. In a cross-sectional population survey in Greenland in 1993-1994, blood lead adjusted for age and sex was found to be associated with the reported consumption of sea birds. Participants reporting less than weekly intake of sea birds had blood lead concentrations...... of approximately 75 microg/L, whereas those who reported eating sea birds several times a week had concentrations of approximately 110 microg/L, and those who reported daily intake had concentrations of 170 microg/L (p = 0.01). Blood lead was not associated with dietary exposure to other local or imported food...

  11. Quantification of the effects of dependence on human error probabilities

    International Nuclear Information System (INIS)

    Bell, B.J.; Swain, A.D.

    1980-01-01

    In estimating the probabilities of human error in the performance of a series of tasks in a nuclear power plant, the situation-specific characteristics of the series must be considered. A critical factor not to be overlooked in this estimation is the dependence or independence that pertains to any of the several pairs of task performances. In discussing the quantification of the effects of dependence, the event tree symbology described will be used. In any series of tasks, the only dependence considered for quantification in this document will be that existing between the task of interest and the immediately preceeding task. Tasks performed earlier in the series may have some effect on the end task, but this effect is considered negligible

  12. 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.

  13. 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

  14. 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

  15. Scaffolding--How Can Contingency Lead to Successful Learning When Dealing with Errors?

    Science.gov (United States)

    Wischgoll, Anke; Pauli, Christine; Reusser, Kurt

    2015-01-01

    Errors indicate learners' misunderstanding and can provide learning opportunities. Providing learning support which is contingent on learners' needs when errors occur is considered effective for developing learners' understanding. The current investigation examines how tutors and tutees interact productively with errors when working on a…

  16. 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.

  17. 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)

  18. 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....

  19. 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

  20. 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.

  1. Findings from analysing and quantifying human error using current methods

    International Nuclear Information System (INIS)

    Dang, V.N.; Reer, B.

    1999-01-01

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

  2. 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

  3. Interpretations of systematic errors in the NCEP Climate Forecast System at lead times of 2, 4, 8, ..., 256 days

    Directory of Open Access Journals (Sweden)

    Siwon Song

    2012-09-01

    Full Text Available The climatology of mean bias errors (relative to 1-day forecasts was examined in a 20-year hindcast set from version 1 of the Climate Forecast System (CFS, for forecast lead times of 2, 4, 8, 16, ... 256 days, verifying in different seasons. Results mostly confirm the simple expectation that atmospheric model biases should be evident at short lead (2–4 days, while soil moisture errors develop over days-weeks and ocean errors emerge over months. A further simplification is also evident: surface temperature bias patterns have nearly fixed geographical structure, growing with different time scales over land and ocean. The geographical pattern has mostly warm and dry biases over land and cool bias over the oceans, with two main exceptions: (1 deficient stratocumulus clouds cause warm biases in eastern subtropical oceans, and (2 high latitude land is too cold in boreal winter. Further study of the east Pacific cold tongue-Intertropical Convergence Zone (ITCZ complex shows a possible interaction between a rapidly-expressed atmospheric model bias (poleward shift of deep convection beginning at day 2 and slow ocean dynamics (erroneously cold upwelling along the equator in leads > 1 month. Further study of the high latitude land cold bias shows that it is a thermal wind balance aspect of the deep polar vortex, not just a near-surface temperature error under the wintertime inversion, suggesting that its development time scale of weeks to months may involve long timescale processes in the atmosphere, not necessarily in the land model. Winter zonal wind errors are small in magnitude, but a refractive index map shows that this can cause modest errors in Rossby wave ducting. Finally, as a counterpoint to our initial expectations about error growth, a case of non-monotonic error growth is shown: velocity potential bias grows with lead on a time scale of weeks, then decays over months. It is hypothesized that compensations between land and ocean errors may

  4. 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.

  5. 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

  6. 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

  7. 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

  8. 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)

  9. Does the A-not-B error in adult pet dogs indicate sensitivity to human communication?

    Science.gov (United States)

    Kis, Anna; Topál, József; Gácsi, Márta; Range, Friederike; Huber, Ludwig; Miklósi, Adám; Virányi, Zsófia

    2012-07-01

    Recent dog-infant comparisons have indicated that the experimenter's communicative signals in object hide-and-search tasks increase the probability of perseverative (A-not-B) errors in both species (Topál et al. 2009). These behaviourally similar results, however, might reflect different mechanisms in dogs and in children. Similar errors may occur if the motor response of retrieving the object during the A trials cannot be inhibited in the B trials or if the experimenter's movements and signals toward the A hiding place in the B trials ('sham-baiting') distract the dogs' attention. In order to test these hypotheses, we tested dogs similarly to Topál et al. (2009) but eliminated the motor search in the A trials and 'sham-baiting' in the B trials. We found that neither an inability to inhibit previously rewarded motor response nor insufficiencies in their working memory and/or attention skills can explain dogs' erroneous choices. Further, we replicated the finding that dogs have a strong tendency to commit the A-not-B error after ostensive-communicative hiding and demonstrated the crucial effect of socio-communicative cues as the A-not-B error diminishes when location B is ostensively enhanced. These findings further support the hypothesis that the dogs' A-not-B error may reflect a special sensitivity to human communicative cues. Such object-hiding and search tasks provide a typical case for how susceptibility to human social signals could (mis)lead domestic dogs.

  10. High human exposure to lead through consumption of birds hunted with lead shot

    International Nuclear Information System (INIS)

    Johansen, P.; Asmund, G.; Riget, F.

    2004-01-01

    Lead shot contaminates the edible parts of birds so that tolerable human lead intake is exceeded. - We assess lead contamination of Greenland seabirds killed with lead shot having studied thick-billed murre and common eider, the two most important species in the diet. The lead concentration is very high in meat of eiders killed with lead shot (mean 6.1 μg/g-wet wt, 95% CL 2.1-12). This level is about 44 times higher than in drowned eiders and eight times higher than in shot murres. Analyzing whole breasts instead of sub-samples reveals about seven times higher lead levels in birds' meat. We conclude that in some cases the lead intake by Greenland bird eaters will largely exceed the FAO/WHO tolerable lead intake guideline and that lead shot is a more important source of lead in the diet than previously estimated

  11. 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

  12. 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.

  13. 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

  14. 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.

  15. 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

  16. 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)

  17. 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.

  18. 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.

  19. 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.

  20. 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

  1. 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

  2. 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

  3. 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

  4. Online visual feedback during error-free channel trials leads to active unlearning of movement dynamics: evidence for adaptation to trajectory prediction errors.

    Directory of Open Access Journals (Sweden)

    Angel Lago-Rodriguez

    2016-09-01

    Full Text Available Prolonged exposure to movement perturbations leads to creation of motor memories which decay towards previous states when the perturbations are removed. However, it remains unclear whether this decay is due only to a spontaneous and passive recovery of the previous state. It has recently been reported that activation of reinforcement-based learning mechanisms delays the onset of the decay. This raises the question whether other motor learning mechanisms may also contribute to the retention and/or decay of the motor memory. Therefore, we aimed to test whether mechanisms of error-based motor adaptation are active during the decay of the motor memory. Forty-five right-handed participants performed point-to-point reaching movements under an external dynamic perturbation. We measured the expression of the motor memory through error-clamped (EC trials, in which lateral forces constrained movements to a straight line towards the target. We found greater and faster decay of the motor memory for participants who had access to full online visual feedback during these EC trials (Cursor group, when compared with participants who had no EC feedback regarding movement trajectory (Arc group. Importantly, we did not find between-group differences in adaptation to the external perturbation. In addition, we found greater decay of the motor memory when we artificially increased feedback errors through the manipulation of visual feedback (Augmented-Error group. Our results then support the notion of an active decay of the motor memory, suggesting that adaptive mechanisms are involved in correcting for the mismatch between predicted movement trajectories and actual sensory feedback, which leads to greater and faster decay of the motor memory.

  5. Errors in Postural Preparation Lead to Increased Choice Reaction Times for Step Initiation in Older Adults

    Science.gov (United States)

    Nutt, John G.; Horak, Fay B.

    2011-01-01

    Background. This study asked whether older adults were more likely than younger adults to err in the initial direction of their anticipatory postural adjustment (APA) prior to a step (indicating a motor program error), whether initial motor program errors accounted for reaction time differences for step initiation, and whether initial motor program errors were linked to inhibitory failure. Methods. In a stepping task with choice reaction time and simple reaction time conditions, we measured forces under the feet to quantify APA onset and step latency and we used body kinematics to quantify forward movement of center of mass and length of first step. Results. Trials with APA errors were almost three times as common for older adults as for younger adults, and they were nine times more likely in choice reaction time trials than in simple reaction time trials. In trials with APA errors, step latency was delayed, correlation between APA onset and step latency was diminished, and forward motion of the center of mass prior to the step was increased. Participants with more APA errors tended to have worse Stroop interference scores, regardless of age. Conclusions. The results support the hypothesis that findings of slow choice reaction time step initiation in older adults are attributable to inclusion of trials with incorrect initial motor preparation and that these errors are caused by deficits in response inhibition. By extension, the results also suggest that mixing of trials with correct and incorrect initial motor preparation might explain apparent choice reaction time slowing with age in upper limb tasks. PMID:21498431

  6. 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.

  7. 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

  8. 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.

  9. 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.

  10. 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

  11. 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

  12. 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.

  13. 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

  14. 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)

  15. 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

  16. Wrinkles in the rare biosphere: Pyrosequencing errors can lead to artificial inflation of diversity estimates

    Energy Technology Data Exchange (ETDEWEB)

    Kunin, Victor; Engelbrektson, Anna; Ochman, Howard; Hugenholtz, Philip

    2009-08-01

    Massively parallel pyrosequencing of the small subunit (16S) ribosomal RNA gene has revealed that the extent of rare microbial populations in several environments, the 'rare biosphere', is orders of magnitude higher than previously thought. One important caveat with this method is that sequencing error could artificially inflate diversity estimates. Although the per-base error of 16S rDNA amplicon pyrosequencing has been shown to be as good as or lower than Sanger sequencing, no direct assessments of pyrosequencing errors on diversity estimates have been reported. Using only Escherichia coli MG1655 as a reference template, we find that 16S rDNA diversity is grossly overestimated unless relatively stringent read quality filtering and low clustering thresholds are applied. In particular, the common practice of removing reads with unresolved bases and anomalous read lengths is insufficient to ensure accurate estimates of microbial diversity. Furthermore, common and reproducible homopolymer length errors can result in relatively abundant spurious phylotypes further confounding data interpretation. We suggest that stringent quality-based trimming of 16S pyrotags and clustering thresholds no greater than 97% identity should be used to avoid overestimates of the rare biosphere.

  17. 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)

  18. 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.

  19. 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.

  20. 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)

  1. 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

  2. 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.

  3. 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.)

  4. 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

  5. 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.

  6. Lead shot from hunting as a source of lead in human blood

    International Nuclear Information System (INIS)

    Johansen, Poul; Pedersen, Henning Sloth; Asmund, Gert; Riget, Frank

    2006-01-01

    This study investigates the relationship between the intake of birds hunted with lead shot and the lead concentration in human blood. Fifty adult men from Nuuk, Greenland took part in the study. From September 2003 to June 2004 they regularly gave blood samples and recorded how many birds they ate. We found a clear relationship between the number of bird meals and blood lead and also a clear seasonal variation. The concentration was highest in mid-winter when bird consumption is at its highest. Blood lead was low (15 μg/L, mean concentration) among the participants reporting not eating birds. Among those reporting to eat birds regularly, blood lead was significantly higher, up to 128 μg/L (mean concentration). Concentrations depended on the frequency of bird meals: the more the bird meals, the higher the resulting blood lead. This clear relationship points to lead shot as the dominating lead source to people in Greenland. - Birds hunted with lead shot and consumed are a source of lead in human blood

  7. Lead shot from hunting as a source of lead in human blood

    Energy Technology Data Exchange (ETDEWEB)

    Johansen, Poul [National Environmental Research Institute, Frederiksborgvej 399, DK-4000 Roskilde (Denmark)]. E-mail: poj@dmu.dk; Pedersen, Henning Sloth [Primary Health Care Center, DK-3900 Nuuk (Greenland); Asmund, Gert [National Environmental Research Institute, Frederiksborgvej 399, DK-4000 Roskilde (Denmark); Riget, Frank [National Environmental Research Institute, Frederiksborgvej 399, DK-4000 Roskilde (Denmark)

    2006-07-15

    This study investigates the relationship between the intake of birds hunted with lead shot and the lead concentration in human blood. Fifty adult men from Nuuk, Greenland took part in the study. From September 2003 to June 2004 they regularly gave blood samples and recorded how many birds they ate. We found a clear relationship between the number of bird meals and blood lead and also a clear seasonal variation. The concentration was highest in mid-winter when bird consumption is at its highest. Blood lead was low (15 {mu}g/L, mean concentration) among the participants reporting not eating birds. Among those reporting to eat birds regularly, blood lead was significantly higher, up to 128 {mu}g/L (mean concentration). Concentrations depended on the frequency of bird meals: the more the bird meals, the higher the resulting blood lead. This clear relationship points to lead shot as the dominating lead source to people in Greenland. - Birds hunted with lead shot and consumed are a source of lead in human blood.

  8. Lead remediation and changes in human lead exposure: some physiological and biokinetic dimensions.

    Science.gov (United States)

    Mushak, Paul

    2003-02-15

    This paper presents a qualitative and quantitative analysis of the various aspects of lead remediation effectiveness with particular reference to human health risk assessment. One of the key elements of lead remediation efforts at such sites as those under the Superfund program deals with populations at elevated exposure and toxicity risk in the proximity of, or at, the site of remediation, especially remediation workers, workers at other tasks on sites that were remediated down to some action level of lead concentration in soils, and groups at risk in nearby communities. A second element has to do with how one measures or models lead exposure changes with special reference to baseline and post-remediation conditions. Various biomarkers of lead exposure can be employed, but their use requires detailed knowledge of what results using each means. The most commonly used approach is measurement of blood lead (Pb-B). Recognized limitations in the use of Pb-B has led to the use of predictive Pb exposure models, which are less vulnerable to the many behavioral, physiological, and environmental parameters that can distort isolated or 'single shot' Pb-B testings. A third aspect covered in this paper presents various physiological factors that affect the methods by which one evaluates Pb remediation effectiveness. Finally, this article offers an integrated look at how lead remediation actions directed at one lead source or pathway affect the total lead exposure picture for human populations at elevated lead exposure and toxicity risk.

  9. Bioavailability of lead in rats fed human diets

    International Nuclear Information System (INIS)

    Kostial, K.; Kello, D.

    1979-01-01

    The bioavailability of lead was studied in rats fed various baby foods (Babymix-turkey, Babymix-vegetables, Frutolino-fruit, Frutamix-bananas, Babyron-S-26, Truefood), cow's milk, bread, liver and standard rat diet. Lead absorption was determined by measuring the whole body retention of 203 Pb 6 days after a single oral application. Highest absorption values ranging from 17 to 20% were obtained in animals fed cow's milk and fruit foods. Rats on other human diets absorbed between 3 and 8% of the radioactive lead dose. Only in animals on rat diet lead absorption was below 1%. It is concluded that rats fed human diets show absorption values similar to those in humans. This might indicate that the bioavailability of lead is primarily dependent on dietary habits. This experimental model, if confirmed by further work, might be useful for obtaining preliminary data on the bioavailability of metals from various foods

  10. 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

  11. Technical Error During Deployment Leads to Vena Cava Filter Migration and Massive Pulmonary Embolism

    International Nuclear Information System (INIS)

    Fotiadis, Nikolas I.; Sabharwal, Tarun; Dourado, Renato; Fikrat, Shabbo; Adam, Andreas

    2008-01-01

    The Guenther Tulip vena cava filter is a safe, effective, well-established device for pulmonary embolism prophylaxis. We report a patient in whom there was migration of the filter to the right atrium, 2 weeks after insertion, caused by a technical error during deployment. An attempt to retrieve the filter percutaneously failed, necessitating removal at open-heart surgery. The potential causes of migration are described and the lessons learned from this unusual case are outlined.

  12. Role of data and judgment in modeling human errors

    International Nuclear Information System (INIS)

    Carnino, A.

    1986-01-01

    Human beings are not a simple component. This is why prediction of human behaviour in a quantitative way is so difficult. For human reliability analysis, the data sources that can be used are the following: operating experience and incident reports, data banks, data from literature, data collected from simulators, data established by expert judgement. The factors important for conducting a good human reliability analysis are then discussed, including the uncertainties to be associated with. (orig.)

  13. 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

  14. 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.

  15. 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.

  16. 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...

  17. Errors in data interpretation from genetic variation of human analytes

    OpenAIRE

    Howie, Heather L.; Delaney, Meghan; Wang, Xiaohong; Er, Lay See; Kapp, Linda; Lebedev, Jenna N.; Zimring, James C.

    2017-01-01

    In recent years, the extent of our vulnerability to misinterpretation due to poorly characterized reagents has become an issue of great concern. Antibody reagents have been identified as a major source of error, contributing to the ?reproducibility crisis.? In the current report, we define an additional dimension of the crisis; in particular, we define variation of the targets being analyzed. We report that natural variation in the immunoglobulin ?constant? region alters the reactivity with c...

  18. 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)

  19. 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.

  20. 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

  1. 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.

  2. 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

  3. 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

  4. 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

  5. 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

  6. 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

  7. 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)

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

    International Nuclear Information System (INIS)

    Ghertman, F.; Dietz, P.

    1985-01-01

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

  9. 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)

  10. 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

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

    International Nuclear Information System (INIS)

    Takagawa, Kenichi

    2009-01-01

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

  12. 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.

  13. 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.

  14. Strategies For Human Exploration Leading To Human Colonization of Space

    Science.gov (United States)

    Smitherman, David; Everett, Harmon

    2009-01-01

    Enabling the commercial development of space is key to the future colonization of space and key to a viable space exploration program. Without commercial development following in the footsteps of exploration it is difficult to justify and maintain public interest in the efforts. NASA's exploration program has suffered from the lack of a good commercial economic strategy for decades. Only small advances in commercial space have moved forward, and only up to Earth orbit with the commercial satellite industry. A way to move beyond this phase is to begin the establishment of human commercial activities in space in partnership with the human exploration program. In 2007 and 2008, the authors researched scenarios to make space exploration and commercial space development more feasible as part of their graduate work in the Space Architecture Program at the Sasakawa International Center for Space Architecture at the University of Houston, Houston, Texas. Through this research it became apparent that the problems facing future colonization are much larger than the technology being developed or the international missions that our space agencies are pursuing. These issues are addressed in this paper with recommendations for space exploration, commercial development, and space policy that are needed to form a strategic plan for human expansion into space. In conclusion, the authors found that the current direction in space as carried out by our space agencies around the world is definitely needed, but is inadequate and incapable of resolving all of the issues that inhibit commercial space development. A bolder vision with strategic planning designed to grow infrastructures and set up a legal framework for commercial markets will go a long way toward enabling the future colonization of space.

  15. 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.

  16. 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.

  17. 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...

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

    KAUST Repository

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

    2010-01-01

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

  19. 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

  20. Effect of Lead on Human Middle Ear Epithelial Cells

    Directory of Open Access Journals (Sweden)

    Shin Hye Kim

    2018-01-01

    Full Text Available Lead is a ubiquitous metal in the environment, but no studies have examined lead toxicity on the middle ear. Here, we investigated lead toxicity and its mechanism in human middle ear epithelial cells (HMEECs. Moreover, we investigated the protective effects of amniotic membrane extract (AME and chorionic membrane extract (CME against lead toxicity in HMEECs. Cell viability was analyzed using the cell counting kit, and reactive oxygen species (ROS activity was measured using a cellular ROS detection kit. After lead(II acetate trihydrate treatment, mRNA levels of various genes were assessed by semiquantitative real-time polymerase chain reaction. Following treatment with AME or CME after lead exposure, the changes in cell viability, ROS activity, and gene expression were analyzed. Exposure to >100 μg/mL of lead(II acetate trihydrate caused a significant decrease in cell viability and increased ROS production in HMEECs. Lead exposure significantly increased the mRNA expression of genes encoding inflammatory cytokines and mucins. Administration of AME or CME restored cell viability, reduced ROS activity, and ameliorated mRNA levels. Our findings suggest that environmental lead exposure is related to the development of otitis media, and AME and CME may have antioxidative and anti-inflammatory effects against lead toxicity.

  1. 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)

  2. 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

  3. Error propagation in spatial modeling of public health data: a simulation approach using pediatric blood lead level data for Syracuse, New York.

    Science.gov (United States)

    Lee, Monghyeon; Chun, Yongwan; Griffith, Daniel A

    2018-04-01

    Lead poisoning produces serious health problems, which are worse when a victim is younger. The US government and society have tried to prevent lead poisoning, especially since the 1970s; however, lead exposure remains prevalent. Lead poisoning analyses frequently use georeferenced blood lead level data. Like other types of data, these spatial data may contain uncertainties, such as location and attribute measurement errors, which can propagate to analysis results. For this paper, simulation experiments are employed to investigate how selected uncertainties impact regression analyses of blood lead level data in Syracuse, New York. In these simulations, location error and attribute measurement error, as well as a combination of these two errors, are embedded into the original data, and then these data are aggregated into census block group and census tract polygons. These aggregated data are analyzed with regression techniques, and comparisons are reported between the regression coefficients and their standard errors for the error added simulation results and the original results. To account for spatial autocorrelation, the eigenvector spatial filtering method and spatial autoregressive specifications are utilized with linear and generalized linear models. Our findings confirm that location error has more of an impact on the differences than does attribute measurement error, and show that the combined error leads to the greatest deviations. Location error simulation results show that smaller administrative units experience more of a location error impact, and, interestingly, coefficients and standard errors deviate more from their true values for a variable with a low level of spatial autocorrelation. These results imply that uncertainty, especially location error, has a considerable impact on the reliability of spatial analysis results for public health data, and that the level of spatial autocorrelation in a variable also has an impact on modeling results.

  4. 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

  5. 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

  6. The detrimental effects of lead on human and animal health

    Directory of Open Access Journals (Sweden)

    Mohammed Abdulrazzaq Assi

    2016-06-01

    Full Text Available Lead, a chemical element in the carbon group with symbol Pb (from Latin: Plumbum, meaning “the liquid silver” and has an atomic number 82 in the periodic table. It was the first element that was characterized by its kind of toxicity. In animal systems, lead (Pb has been incriminated in a wide spectrum of toxic effects and it is considered one of the persistent ubiquitous heavy metals. Being exposed to this metal could lead to the change of testicular functions in human beings as well as in the wildlife. The lead poising is a real threat to the public health, especially in the developing countries. Accordingly, great efforts on the part of the occupational and public health have been taken to curb the dangers of this metal. Hematopoietic, renal, reproductive, and central nervous system are among the parts of the human body and systems that are vulnerable toward the dangers following exposure to high level of Pb. In this review, we discussed the massive harmful impact that leads acetate toxicity has on the animals and the worrying fact that this harmful toxicant can be found quite easily in the environment and abundance. Highlighting its (Pb effects on various organs in the biological systems, its economic, as well as scientific importance, with the view to educate the public/professionals who work in this area. In this study, we focus on the current studies and research related to lead toxicity in animals and also to a certain extent toward human as well.

  7. 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...

  8. 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

  9. 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

  10. 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

  11. From human error to organizational failure: a historical perspective

    International Nuclear Information System (INIS)

    Guarnieri, F.; Cambon, J.; Boissieres, I.

    2008-01-01

    This article hinges around three main parts.The first part goes back over the foundations of the human factor approach. It introduces the basic assumptions as well as some of the methods which have been developed. The second part accounts for the reasons why organizational factors have drawn our attention at the first place underlying two major points: the limits of the human factor approach but also the original contribution and the innovative aspect of sociology. At last, the third part describes the keystone principles and hypotheses on which lay the foundations of the organizational factor approach and draws a brief overview of the methods which have lately been implanted within the industrial world. (authors)

  12. 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.

  13. 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

  14. 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.

  15. Evaluating a medical error taxonomy.

    OpenAIRE

    Brixey, Juliana; Johnson, Todd R.; Zhang, Jiajie

    2002-01-01

    Healthcare has been slow in using human factors principles to reduce medical errors. The Center for Devices and Radiological Health (CDRH) recognizes that a lack of attention to human factors during product development may lead to errors that have the potential for patient injury, or even death. In response to the need for reducing medication errors, the National Coordinating Council for Medication Errors Reporting and Prevention (NCC MERP) released the NCC MERP taxonomy that provides a stand...

  16. 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

  17. 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

  18. 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...

  19. 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.)

  20. 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

  1. 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)

  2. Human geography of New Orleans' high-lead geochemical setting.

    Science.gov (United States)

    Campanella, Richard; Mielke, Howard W

    2008-12-01

    Previous soil lead studies in New Orleans focused on the geochemical footprint and its health impacts. This study examines the human geography of race, income, and age in pre-Katrina metropolitan New Orleans within the context of lead accumulation in soils. Sample points of soil lead data (n = 5,467) collected in 1998-2000 were mapped in a geographic information system (GIS), binned into 9 ranges, and queried by (1) 2000 Census racial demographic data, (2) 1999 median household income, and (3) 2000 age data. The absolute population generally declines as lead levels increase except at lead levels from 200-400 to 400-1,000 mg/kg when population increases; the African-American population comprises a disproportionate share of this cohort. The high-lead areas occur in the inner city, home to the largest populations of African-Americans in New Orleans. The mean household income curve indicates that lower economic groups are at risk to higher levels of lead. A total of 44,701 children under the age of 5 years, plus 123,579 children aged 5-17, lived in census block groups containing at least one sample point with over 100 mg/kg lead, and these include 23,124 and 64,064 young people, respectively, who live near at least one point over 400 mg/kg. Lead exposure affects a panoply of outcomes that influence the health and welfare of the community. Unless corrected, children are likely to return to the same or, because of lack of lead-safe practices during renovation, even higher exposure risks than before the flooding of New Orleans.

  3. 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.

  4. 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

  5. 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

  6. 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...

  7. 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.

  8. 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)

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

    International Nuclear Information System (INIS)

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

    1991-01-01

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

  10. 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.

  11. 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.

  12. 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

  13. 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

  14. 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.,.

  15. 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.

  16. A system dynamic simulation model for managing the human error in power tools industries

    Science.gov (United States)

    Jamil, Jastini Mohd; Shaharanee, Izwan Nizal Mohd

    2017-10-01

    In the era of modern and competitive life of today, every organization will face the situations in which the work does not proceed as planned when there is problems occur in which it had to be delay. However, human error is often cited as the culprit. The error that made by the employees would cause them have to spend additional time to identify and check for the error which in turn could affect the normal operations of the company as well as the company's reputation. Employee is a key element of the organization in running all of the activities of organization. Hence, work performance of the employees is a crucial factor in organizational success. The purpose of this study is to identify the factors that cause the increasing errors make by employees in the organization by using system dynamics approach. The broadly defined targets in this study are employees in the Regional Material Field team from purchasing department in power tools industries. Questionnaires were distributed to the respondents to obtain their perceptions on the root cause of errors make by employees in the company. The system dynamics model was developed to simulate the factor of the increasing errors make by employees and its impact. The findings of this study showed that the increasing of error make by employees was generally caused by the factors of workload, work capacity, job stress, motivation and performance of employees. However, this problem could be solve by increased the number of employees in the organization.

  17. 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.

  18. 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)

  19. 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

  20. 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)

  1. 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

  2. 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)

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

    International Nuclear Information System (INIS)

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

    2008-02-01

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

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

    Energy Technology Data Exchange (ETDEWEB)

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

    2008-02-15

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

  5. 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

  6. 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)

  7. 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

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

    NARCIS (Netherlands)

    Karanikas, Nektarios

    2015-01-01

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

  9. The human fallibility of scientists : Dealing with error and bias in academic research

    NARCIS (Netherlands)

    Veldkamp, Coosje

    2017-01-01

    THE HUMAN FALLIBILITY OF SCIENTISTS Dealing with error and bias in academic research Recent studies have highlighted that not all published findings in the scientific lit¬erature are trustworthy, suggesting that currently implemented control mechanisms such as high standards for the reporting of

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

    International Nuclear Information System (INIS)

    Goodstein, L.P.

    1977-01-01

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

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

    International Nuclear Information System (INIS)

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

    2008-01-01

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

  12. 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)

  13. 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

  14. 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.)

  15. Bias correction by use of errors-in-variables regression models in studies with K-X-ray fluorescence bone lead measurements.

    Science.gov (United States)

    Lamadrid-Figueroa, Héctor; Téllez-Rojo, Martha M; Angeles, Gustavo; Hernández-Ávila, Mauricio; Hu, Howard

    2011-01-01

    In-vivo measurement of bone lead by means of K-X-ray fluorescence (KXRF) is the preferred biological marker of chronic exposure to lead. Unfortunately, considerable measurement error associated with KXRF estimations can introduce bias in estimates of the effect of bone lead when this variable is included as the exposure in a regression model. Estimates of uncertainty reported by the KXRF instrument reflect the variance of the measurement error and, although they can be used to correct the measurement error bias, they are seldom used in epidemiological statistical analyzes. Errors-in-variables regression (EIV) allows for correction of bias caused by measurement error in predictor variables, based on the knowledge of the reliability of such variables. The authors propose a way to obtain reliability coefficients for bone lead measurements from uncertainty data reported by the KXRF instrument and compare, by the use of Monte Carlo simulations, results obtained using EIV regression models vs. those obtained by the standard procedures. Results of the simulations show that Ordinary Least Square (OLS) regression models provide severely biased estimates of effect, and that EIV provides nearly unbiased estimates. Although EIV effect estimates are more imprecise, their mean squared error is much smaller than that of OLS estimates. In conclusion, EIV is a better alternative than OLS to estimate the effect of bone lead when measured by KXRF. Copyright © 2010 Elsevier Inc. All rights reserved.

  16. 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

  17. 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)

  18. 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)

  19. Development of a framework to estimate human error for diagnosis tasks in advanced control room

    International Nuclear Information System (INIS)

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

    2014-01-01

    In the emergency situation of nuclear power plants (NPPs), a diagnosis of the occurring events is crucial for managing or controlling the plant to a safe and stable condition. If the operators fail to diagnose the occurring events or relevant situations, their responses can eventually inappropriate or inadequate Accordingly, huge researches have been performed to identify the cause of diagnosis error and estimate the probability of diagnosis error. D.I Gertman et al. asserted that 'the cognitive failures stem from erroneous decision-making, poor understanding of rules and procedures, and inadequate problem solving and this failures may be due to quality of data and people's capacity for processing information'. Also many researchers have asserted that human-system interface (HSI), procedure, training and available time are critical factors to cause diagnosis error. In nuclear power plants, a diagnosis of the event is critical for safe condition of the system. As advanced main control room is being adopted in nuclear power plants, the operators may obtain the plant data via computer-based HSI and procedure. Also many researchers have asserted that HSI, procedure, training and available time are critical factors to cause diagnosis error. In this regards, using simulation data, diagnosis errors and its causes were identified. From this study, some useful insights to reduce diagnosis errors of operators in advanced main control room were provided

  20. 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

  1. SIMULATED HUMAN ERROR PROBABILITY AND ITS APPLICATION TO DYNAMIC HUMAN FAILURE EVENTS

    Energy Technology Data Exchange (ETDEWEB)

    Herberger, Sarah M.; Boring, Ronald L.

    2016-10-01

    Abstract Objectives: Human reliability analysis (HRA) methods typically analyze human failure events (HFEs) at the overall task level. For dynamic HRA, it is important to model human activities at the subtask level. There exists a disconnect between dynamic subtask level and static task level that presents issues when modeling dynamic scenarios. For example, the SPAR-H method is typically used to calculate the human error probability (HEP) at the task level. As demonstrated in this paper, quantification in SPAR-H does not translate to the subtask level. Methods: Two different discrete distributions were generated for each SPAR-H Performance Shaping Factor (PSF) to define the frequency of PSF levels. The first distribution was a uniform, or uninformed distribution that assumed the frequency of each PSF level was equally likely. The second non-continuous distribution took the frequency of PSF level as identified from an assessment of the HERA database. These two different approaches were created to identify the resulting distribution of the HEP. The resulting HEP that appears closer to the known distribution, a log-normal centered on 1E-3, is the more desirable. Each approach then has median, average and maximum HFE calculations applied. To calculate these three values, three events, A, B and C are generated from the PSF level frequencies comprised of subtasks. The median HFE selects the median PSF level from each PSF and calculates HEP. The average HFE takes the mean PSF level, and the maximum takes the maximum PSF level. The same data set of subtask HEPs yields starkly different HEPs when aggregated to the HFE level in SPAR-H. Results: Assuming that each PSF level in each HFE is equally likely creates an unrealistic distribution of the HEP that is centered at 1. Next the observed frequency of PSF levels was applied with the resulting HEP behaving log-normally with a majority of the values under 2.5% HEP. The median, average and maximum HFE calculations did yield

  2. 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

  3. 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

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

    International Nuclear Information System (INIS)

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

    2003-01-01

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

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

    International Nuclear Information System (INIS)

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

    2003-01-01

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

  6. 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.

  7. 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.

  8. 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

  9. Determining tissue-lead levels in large game mammals harvested with lead bullets: human health concerns.

    Science.gov (United States)

    Tsuji, L J S; Wainman, B C; Jayasinghe, R K; VanSpronsen, E P; Liberda, E N

    2009-04-01

    Recently, the use of lead isotope ratios has definitively identified lead ammunition as a source of lead exposure for First Nations people, but the isotope ratios for lead pellets and bullets were indistinguishable. Thus, lead-contaminated meat from game harvested with lead bullets may also be contributing to the lead body burden; however, few studies have determined if lead bullet fragments are present in big game carcasses. We found elevated tissue-lead concentrations (up to 5,726.0 microg/g ww) in liver (5/9) and muscle (6/7) samples of big game harvested with lead bullets and radiographic evidence of lead fragments. Thus, we would advise that the tissue surrounding the wound channel be removed and discarded, as this tissue may be contaminated by lead bullet fragments.

  10. 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)

  11. A method to deal with installation errors of wearable accelerometers for human activity recognition

    International Nuclear Information System (INIS)

    Jiang, Ming; Wang, Zhelong; Shang, Hong; Li, Hongyi; Wang, Yuechao

    2011-01-01

    Human activity recognition (HAR) by using wearable accelerometers has gained significant interest in recent years in a range of healthcare areas, including inferring metabolic energy expenditure, predicting falls, measuring gait parameters and monitoring daily activities. The implementation of HAR relies heavily on the correctness of sensor fixation. The installation errors of wearable accelerometers may dramatically decrease the accuracy of HAR. In this paper, a method is proposed to improve the robustness of HAR to the installation errors of accelerometers. The method first calculates a transformation matrix by using Gram–Schmidt orthonormalization in order to eliminate the sensor's orientation error and then employs a low-pass filter with a cut-off frequency of 10 Hz to eliminate the main effect of the sensor's misplacement. The experimental results showed that the proposed method obtained a satisfactory performance for HAR. The average accuracy rate from ten subjects was 95.1% when there were no installation errors, and was 91.9% when installation errors were involved in wearable accelerometers

  12. Identification and Evaluation of Human Errors in the Medication Process Using the Extended CREAM Technique

    Directory of Open Access Journals (Sweden)

    Iraj Mohammadfam

    2017-10-01

    Full Text Available Background Medication process is a powerful instrument for curing patients. Obeying the commands of this process has an important role in the treatment and provision of care to patients. Medication error, as a complicated process, can occur in any stage of this process, and to avoid it, appropriate decision-making, cognition, and performance of the hospital staff are needed. Objectives The present study aimed at identifying and evaluating the nature and reasons of human errors in the medication process in a hospital using the extended CREAM method. Methods This was a qualitative and cross-sectional study conducted in a hospital in Hamadan. In this study, first, the medication process was selected as a critical issue based on the opinions of experts, specialists, and experienced individuals in the nursing and medical departments. Then, the process was analyzed into relative steps and substeps using the method of HTA and was evaluated using extended CREAM technique considering the probability of human errors. Results Based on the findings achieved through the basic CREAM method, the highest CFPt was in the step of medicine administration to patients (0.056. Moreover, the results revealed that the highest CFPt was in the substeps of calculating the dose of medicine and determining the method of prescription and identifying the patient (0.0796 and 0.0785, respectively. Also, the least CFPt was related to transcribing the prescribed medicine from file to worksheet of medicine (0.0106. Conclusions Considering the critical consequences of human errors in the medication process, holding pharmacological retraining classes, using the principles of executing pharmaceutical orders, increasing medical personnel, reducing working overtime, organizing work shifts, and using error reporting systems are of paramount importance.

  13. 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

  14. 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

  15. 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

  16. A lead isotopic study of the human bioaccessibility of lead in urban soils from Glasgow, Scotland

    International Nuclear Information System (INIS)

    Farmer, John G.; Broadway, Andrew; Cave, Mark R.; Wragg, Joanna; Fordyce, Fiona M.; Graham, Margaret C.; Ngwenya, Bryne T.; Bewley, Richard J.F.

    2011-01-01

    The human bioaccessibility of lead (Pb) in Pb-contaminated soils from the Glasgow area was determined by the Unified Bioaccessibility Research Group of Europe (BARGE) Method (UBM), an in vitro physiologically based extraction scheme that mimics the chemical environment of the human gastrointestinal system and contains both stomach and intestine compartments. For 27 soils ranging in total Pb concentration from 126 to 2160 mg kg -1 (median 539 mg kg -1 ), bioaccessibility as determined by the 'stomach' simulation (pH ∼ 1.5) was 46-1580 mg kg -1 , equivalent to 23-77% (mean 52%) of soil total Pb concentration. The corresponding bioaccessibility data for the 'stomach + intestine' simulation (pH ∼ 6.3) were 6-623 mg kg -1 and 2-42% (mean 22%) of soil Pb concentration. The soil 206 Pb/ 207 Pb ratios ranged from 1.057 to 1.175. Three-isotope plots of 208 Pb/ 206 Pb against 206 Pb/ 207 Pb demonstrated that 206 Pb/ 207 Pb ratios were intermediate between values for source end-member extremes of imported Australian Pb ore (1.04) - used in the manufacture of alkyl Pb compounds (1.06-1.10) formerly added to petrol - and indigenous Pb ores/coal (1.17-1.19). The 206 Pb/ 207 Pb ratios of the UBM 'stomach' extracts were similar ( 206 Pb/ 207 Pb ratio was discernible in the UBM. However, the source of Pb appeared to be less important in determining the extent of UBM-bioaccessible Pb than the overall soil total Pb concentration and the soil phases with which the Pb was associated. The significant phases identified in a subset of samples were carbonates, manganese oxides, iron-aluminium oxyhydroxides and clays. - Highlights: → We determined the human bioaccessibility of Pb in urban soils by in vitro extraction. → We determined the isotopic composition of Pb in soils and simulated stomach extracts. → Soil stable Pb isotope ratios (e.g. 206 Pb/ 207 Pb) indicated a range of sources of Pb. → 206 Pb/ 207 Pb ratios in soils and their simulated stomach extracts were very similar

  17. A lead isotopic study of the human bioaccessibility of lead in urban soils from Glasgow, Scotland

    Energy Technology Data Exchange (ETDEWEB)

    Farmer, John G., E-mail: J.G.Farmer@ed.ac.uk [School of GeoSciences, University of Edinburgh, Edinburgh, EH9 3JN, Scotland (United Kingdom); Broadway, Andrew [School of GeoSciences, University of Edinburgh, Edinburgh, EH9 3JN, Scotland (United Kingdom); Cave, Mark R.; Wragg, Joanna [British Geological Survey, Keyworth, Nottingham NG12 5GG, England (United Kingdom); Fordyce, Fiona M. [British Geological Survey, Edinburgh, EH9 3LA, Scotland (United Kingdom); Graham, Margaret C.; Ngwenya, Bryne T. [School of GeoSciences, University of Edinburgh, Edinburgh, EH9 3JN, Scotland (United Kingdom); Bewley, Richard J.F. [URS Corporation Ltd, Manchester, M1 6HS, England (United Kingdom)

    2011-11-01

    The human bioaccessibility of lead (Pb) in Pb-contaminated soils from the Glasgow area was determined by the Unified Bioaccessibility Research Group of Europe (BARGE) Method (UBM), an in vitro physiologically based extraction scheme that mimics the chemical environment of the human gastrointestinal system and contains both stomach and intestine compartments. For 27 soils ranging in total Pb concentration from 126 to 2160 mg kg{sup -1} (median 539 mg kg{sup -1}), bioaccessibility as determined by the 'stomach' simulation (pH {approx} 1.5) was 46-1580 mg kg{sup -1}, equivalent to 23-77% (mean 52%) of soil total Pb concentration. The corresponding bioaccessibility data for the 'stomach + intestine' simulation (pH {approx} 6.3) were 6-623 mg kg{sup -1} and 2-42% (mean 22%) of soil Pb concentration. The soil {sup 206}Pb/{sup 207}Pb ratios ranged from 1.057 to 1.175. Three-isotope plots of {sup 208}Pb/{sup 206}Pb against {sup 206}Pb/{sup 207}Pb demonstrated that {sup 206}Pb/{sup 207}Pb ratios were intermediate between values for source end-member extremes of imported Australian Pb ore (1.04) - used in the manufacture of alkyl Pb compounds (1.06-1.10) formerly added to petrol - and indigenous Pb ores/coal (1.17-1.19). The {sup 206}Pb/{sup 207}Pb ratios of the UBM 'stomach' extracts were similar (< 0.01 difference) to those of the soil for 26 of the 27 samples (r = 0.993, p < 0.001) and lower in 24 of them. A slight preference for lower {sup 206}Pb/{sup 207}Pb ratio was discernible in the UBM. However, the source of Pb appeared to be less important in determining the extent of UBM-bioaccessible Pb than the overall soil total Pb concentration and the soil phases with which the Pb was associated. The significant phases identified in a subset of samples were carbonates, manganese oxides, iron-aluminium oxyhydroxides and clays. - Highlights: {yields} We determined the human bioaccessibility of Pb in urban soils by in vitro extraction. {yields} We

  18. Human error considerations and annunciator effects in determining optimal test intervals for periodically inspected standby systems

    International Nuclear Information System (INIS)

    McWilliams, T.P.; Martz, H.F.

    1981-01-01

    This paper incorporates the effects of four types of human error in a model for determining the optimal time between periodic inspections which maximizes the steady state availability for standby safety systems. Such safety systems are characteristic of nuclear power plant operations. The system is modeled by means of an infinite state-space Markov chain. Purpose of the paper is to demonstrate techniques for computing steady-state availability A and the optimal periodic inspection interval tau* for the system. The model can be used to investigate the effects of human error probabilities on optimal availability, study the benefits of annunciating the standby-system, and to determine optimal inspection intervals. Several examples which are representative of nuclear power plant applications are presented

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

    Energy Technology Data Exchange (ETDEWEB)

    Reer, B

    2004-03-01

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

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

    International Nuclear Information System (INIS)

    Reer, B.

    2004-01-01

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

  1. 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.)

  2. Subsecond dopamine fluctuations in human striatum encode superposed error signals about actual and counterfactual reward

    Science.gov (United States)

    Kishida, Kenneth T.; Saez, Ignacio; Lohrenz, Terry; Witcher, Mark R.; Laxton, Adrian W.; Tatter, Stephen B.; White, Jason P.; Ellis, Thomas L.; Phillips, Paul E. M.; Montague, P. Read

    2016-01-01

    In the mammalian brain, dopamine is a critical neuromodulator whose actions underlie learning, decision-making, and behavioral control. Degeneration of dopamine neurons causes Parkinson’s disease, whereas dysregulation of dopamine signaling is believed to contribute to psychiatric conditions such as schizophrenia, addiction, and depression. Experiments in animal models suggest the hypothesis that dopamine release in human striatum encodes reward prediction errors (RPEs) (the difference between actual and expected outcomes) during ongoing decision-making. Blood oxygen level-dependent (BOLD) imaging experiments in humans support the idea that RPEs are tracked in the striatum; however, BOLD measurements cannot be used to infer the action of any one specific neurotransmitter. We monitored dopamine levels with subsecond temporal resolution in humans (n = 17) with Parkinson’s disease while they executed a sequential decision-making task. Participants placed bets and experienced monetary gains or losses. Dopamine fluctuations in the striatum fail to encode RPEs, as anticipated by a large body of work in model organisms. Instead, subsecond dopamine fluctuations encode an integration of RPEs with counterfactual prediction errors, the latter defined by how much better or worse the experienced outcome could have been. How dopamine fluctuations combine the actual and counterfactual is unknown. One possibility is that this process is the normal behavior of reward processing dopamine neurons, which previously had not been tested by experiments in animal models. Alternatively, this superposition of error terms may result from an additional yet-to-be-identified subclass of dopamine neurons. PMID:26598677

  3. 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.)

  4. Study on relationship of performance shaping factor in human error probability with prevalent stress of PUSPATI TRIGA reactor operators

    Science.gov (United States)

    Rahim, Ahmad Nabil Bin Ab; Mohamed, Faizal; Farid, Mohd Fairus Abdul; Fazli Zakaria, Mohd; Sangau Ligam, Alfred; Ramli, Nurhayati Binti

    2018-01-01

    Human factor can be affected by prevalence stress measured using Depression, Anxiety and Stress Scale (DASS). From the respondents feedback can be summarized that the main factor causes the highest prevalence stress is due to the working conditions that require operators to handle critical situation and make a prompt critical decisions. The relationship between the prevalence stress and performance shaping factors found that PSFFitness and PSFWork Process showed positive Pearson’s Correlation with the score of .763 and .826 while the level of significance, p = .028 and p = .012. These positive correlations with good significant values between prevalence stress and human performance shaping factor (PSF) related to fitness, work processes and procedures. The higher the stress level of the respondents, the higher the score of selected for the PSFs. This is due to the higher levels of stress lead to deteriorating physical health and cognitive also worsened. In addition, the lack of understanding in the work procedures can also be a factor that causes a growing stress. The higher these values will lead to the higher the probabilities of human error occur. Thus, monitoring the level of stress among operators RTP is important to ensure the safety of RTP.

  5. 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)

  6. 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)

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

    International Nuclear Information System (INIS)

    Schlump, Ansgar

    2015-01-01

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

  8. 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

  9. 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

  10. 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.

  11. Determination of lead in human calculi and its effects on renal function of lead occupational workers

    International Nuclear Information System (INIS)

    Memon, F.; Vasandani, A.G.M.

    2016-01-01

    Seventy five samples of renal and eighteen samples of supra gingival calculi of lead recycling workers were collected over the period of seven years (2008-2014) and studied for the accumulation of lead. The results were compared with those of non exposed subjects. The lead content of calculi was investigated for its dependence on type and composition of calculi, blood lead, job status and duration of exposure. The effect of blood lead and renal calculi was also investigated in relation to kidney function of respective subjects. The mean lead levels of various types of calculi were found to follow the order as phosphate > oxalate > urate > cystine while single principal group of supra gingival calculi resulted in lower levels of metal. The lead content of calculi positively correlated with phosphate content of both of the renal (r = 0.655) and supra gingival calculi (r= 0.866). Impaired renal function was more pronounced in active workers and depended on blood lead levels in addition to presence of metal in renal calculi. (author)

  12. 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

  13. 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.

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

    Energy Technology Data Exchange (ETDEWEB)

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

    1982-11-01

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

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

    International Nuclear Information System (INIS)

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

    1982-11-01

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

  16. Human dorsal striatum encodes prediction errors during observational learning of instrumental actions.

    Science.gov (United States)

    Cooper, Jeffrey C; Dunne, Simon; Furey, Teresa; O'Doherty, John P

    2012-01-01

    The dorsal striatum plays a key role in the learning and expression of instrumental reward associations that are acquired through direct experience. However, not all learning about instrumental actions require direct experience. Instead, humans and other animals are also capable of acquiring instrumental actions by observing the experiences of others. In this study, we investigated the extent to which human dorsal striatum is involved in observational as well as experiential instrumental reward learning. Human participants were scanned with fMRI while they observed a confederate over a live video performing an instrumental conditioning task to obtain liquid juice rewards. Participants also performed a similar instrumental task for their own rewards. Using a computational model-based analysis, we found reward prediction errors in the dorsal striatum not only during the experiential learning condition but also during observational learning. These results suggest a key role for the dorsal striatum in learning instrumental associations, even when those associations are acquired purely by observing others.

  17. 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

  18. 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.

  19. 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

  20. A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change

    Directory of Open Access Journals (Sweden)

    Sean Patrick Clifford MD

    2016-05-01

    Full Text Available A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital’s Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.

  1. A Case of Transfusion Error in a Trauma Patient With Subsequent Root Cause Analysis Leading to Institutional Change.

    Science.gov (United States)

    Clifford, Sean Patrick; Mick, Paul Brian; Derhake, Brian Matthew

    2016-01-01

    A 28-year-old man presented emergently to the operating room following a gun-shot injury to his right groin. Our hospital's Massive Transfusion Protocol was initiated as the patient entered the operating room actively hemorrhaging and severely hypotensive. During the aggressive resuscitation efforts, the patient was inadvertently transfused 2 units of packed red blood cells intended for another patient due to a series of errors. Fortunately, the incorrect product was compatible, and the patient recovered from his near-fatal injuries. Root cause analysis was used to review the transfusion error and develop an action plan to help prevent future occurrences.

  2. Neural prediction errors reveal a risk-sensitive reinforcement-learning process in the human brain.

    Science.gov (United States)

    Niv, Yael; Edlund, Jeffrey A; Dayan, Peter; O'Doherty, John P

    2012-01-11

    Humans and animals are exquisitely, though idiosyncratically, sensitive to risk or variance in the outcomes of their actions. Economic, psychological, and neural aspects of this are well studied when information about risk is provided explicitly. However, we must normally learn about outcomes from experience, through trial and error. Traditional models of such reinforcement learning focus on learning about the mean reward value of cues and ignore higher order moments such as variance. We used fMRI to test whether the neural correlates of human reinforcement learning are sensitive to experienced risk. Our analysis focused on anatomically delineated regions of a priori interest in the nucleus accumbens, where blood oxygenation level-dependent (BOLD) signals have been suggested as correlating with quantities derived from reinforcement learning. We first provide unbiased evidence that the raw BOLD signal in these regions corresponds closely to a reward prediction error. We then derive from this signal the learned values of cues that predict rewards of equal mean but different variance and show that these values are indeed modulated by experienced risk. Moreover, a close neurometric-psychometric coupling exists between the fluctuations of the experience-based evaluations of risky options that we measured neurally and the fluctuations in behavioral risk aversion. This suggests that risk sensitivity is integral to human learning, illuminating economic models of choice, neuroscientific models of affective learning, and the workings of the underlying neural mechanisms.

  3. 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

  4. Incident reporting: Its role in aviation safety and the acquisition of human error data

    Science.gov (United States)

    Reynard, W. D.

    1983-01-01

    The rationale for aviation incident reporting systems is presented and contrasted to some of the shortcomings of accident investigation procedures. The history of the United State's Aviation Safety Reporting System (ASRS) is outlined and the program's character explained. The planning elements that resulted in the ASRS program's voluntary, confidential, and non-punitive design are discussed. Immunity, from enforcement action and misuse of the volunteered data, is explained and evaluated. Report generation techniques and the ASRS data analysis process are described; in addition, examples of the ASRS program's output and accomplishments are detailed. Finally, the value of incident reporting for the acquisition of safety information, particularly human error data, is explored.

  5. Intrinsic interactive reinforcement learning - Using error-related potentials for real world human-robot interaction.

    Science.gov (United States)

    Kim, Su Kyoung; Kirchner, Elsa Andrea; Stefes, Arne; Kirchner, Frank

    2017-12-14

    Reinforcement learning (RL) enables robots to learn its optimal behavioral strategy in dynamic environments based on feedback. Explicit human feedback during robot RL is advantageous, since an explicit reward function can be easily adapted. However, it is very demanding and tiresome for a human to continuously and explicitly generate feedback. Therefore, the development of implicit approaches is of high relevance. In this paper, we used an error-related potential (ErrP), an event-related activity in the human electroencephalogram (EEG), as an intrinsically generated implicit feedback (rewards) for RL. Initially we validated our approach with seven subjects in a simulated robot learning scenario. ErrPs were detected online in single trial with a balanced accuracy (bACC) of 91%, which was sufficient to learn to recognize gestures and the correct mapping between human gestures and robot actions in parallel. Finally, we validated our approach in a real robot scenario, in which seven subjects freely chose gestures and the real robot correctly learned the mapping between gestures and actions (ErrP detection (90% bACC)). In this paper, we demonstrated that intrinsically generated EEG-based human feedback in RL can successfully be used to implicitly improve gesture-based robot control during human-robot interaction. We call our approach intrinsic interactive RL.

  6. 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...

  7. 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

  8. Error identification and recovery by student nurses using human patient simulation: opportunity to improve patient safety.

    Science.gov (United States)

    Henneman, Elizabeth A; Roche, Joan P; Fisher, Donald L; Cunningham, Helene; Reilly, Cheryl A; Nathanson, Brian H; Henneman, Philip L

    2010-02-01

    This study examined types of errors that occurred or were recovered in a simulated environment by student nurses. Errors occurred in all four rule-based error categories, and all students committed at least one error. The most frequent errors occurred in the verification category. Another common error was related to physician interactions. The least common errors were related to coordinating information with the patient and family. Our finding that 100% of student subjects committed rule-based errors is cause for concern. To decrease errors and improve safe clinical practice, nurse educators must identify effective strategies that students can use to improve patient surveillance. Copyright 2010 Elsevier Inc. All rights reserved.

  9. MMI design of K-CPS for preventing human errors and enhancing convenient operation

    International Nuclear Information System (INIS)

    Sung, Chan Ho; Jung, Yeon Sub; Oh, Eoung Se; Shin, Young Chul; Lee, Yong Kwan

    2001-01-01

    In order to supplement defects of paper procedure, reduce human errors and enhance convenient operation, computer-based procedure system is being developed. CPS (Computerized Procedure System) including human-factor engineering design concept for KNGR (Korean Next Generation Reactor) has been also developed with the same object. K-CPS(KNGR CPS) has higher level of automation than paper procedure. It is fully integrated with control and monitoring systems. Combining statements and relevant components, which changes dynamically according to plant status enhances readability of procedure. This paper shows general design criteria on computer-based procedure system, the MMI design characteristics of K-CPS and the results of suitability evaluation for K-CPS by operator

  10. 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

  11. 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.

  12. Inborn errors of human STAT1: allelic heterogeneity governs the diversity of immunological and infectious phenotypes

    Science.gov (United States)

    Boisson-Dupuis, Stephanie; Kong, Xiao-Fei; Okada, Satoshi; Cypowyj, Sophie; Puel, Anne; Abel, Laurent; Casanova, Jean-Laurent

    2012-01-01

    The genetic dissection of various human infectious diseases has led to the definition of inborn errors of human STAT1 immunity of four types, including (i) autosomal recessive (AR) complete STAT1 deficiency, (ii) AR partial STAT1 deficiency, (iii) autosomal dominant (AD) STAT1 deficiency, and (iv) AD gain of STAT1 activity. The two types of AR STAT1 defect give rise to a broad infectious phenotype with susceptibility to intramacrophagic bacteria (mostly mycobacteria) and viruses (herpes viruses at least), due principally to the impairment of IFN-γ-mediated and IFN-α/β-mediated immunity, respectively. Clinical outcome depends on the extent to which the STAT1 defect decreases responsiveness to these cytokines. AD STAT1 deficiency selectively predisposes individuals to mycobacterial disease, owing to the impairment of IFN-γ-mediated immunity, as IFN-α/β-mediated immunity is maintained. Finally, AD gain of STAT1 activity is associated with autoimmunity, probably owing to an enhancement of IFN-α/β-mediated immunity. More surprisingly, it is also associated with chronic mucocutaneous candidiasis, through as yet undetermined mechanisms involving an inhibition of the development of IL-17-producing T cells. Thus, germline mutations in human STAT1 define four distinct clinical disorders. Various combinations of viral, mycobacterial and fungal infections are therefore allelic at the human STAT1 locus. These experiments of Nature neatly highlight the clinical and immunological impact of the human genetic dissection of infectious phenotypes. PMID:22651901

  13. Lead concentration in meat from lead-killed moose and predicted human exposure using Monte Carlo simulation.

    Science.gov (United States)

    Lindboe, M; Henrichsen, E N; Høgåsen, H R; Bernhoft, A

    2012-01-01

    Lead-based hunting ammunitions are still common in most countries. On impact such ammunition releases fragments which are widely distributed within the carcass. In Norway, wild game is an important meat source for segments of the population and 95% of hunters use lead-based bullets. In this paper, we have investigated the lead content of ground meat from moose (Alces alces) intended for human consumption in Norway, and have predicted human exposure through this source. Fifty-two samples from different batches of ground meat from moose killed with lead-based bullets were randomly collected. The lead content was measured by atomic absorption spectroscopy. The lead intake from exposure to moose meat over time, depending on the frequency of intake and portion size, was predicted using Monte Carlo simulation. In 81% of the batches, lead levels were above the limit of quantification of 0.03 mg kg(-1), ranging up to 110 mg kg(-1). The mean lead concentration was 5.6 mg kg(-1), i.e. 56 times the European Commission limit for lead in meat. For consumers eating a moderate meat serving (2 g kg(-1) bw), a single serving would give a lead intake of 11 µg kg(-1) bw on average, with maximum of 220 µg kg(-1) bw. Using Monte Carlo simulation, the median (and 97.5th percentile) predicted weekly intake of lead from moose meat was 12 µg kg(-1) bw (27 µg kg(-1) bw) for one serving per week and 25 µg kg(-1) bw (45 µg kg(-1) bw) for two servings per week. The results indicate that the intake of meat from big game shot with lead-based bullets imposes a significant contribution to the total human lead exposure. The provisional tolerable weekly intake set by the World Health Organization (WHO) of 25 µg kg(-1) bw is likely to be exceeded in people eating moose meat on a regular basis. The European Food Safety Authority (EFSA) has recently concluded that adverse effects may be present at even lower exposure doses. Hence, even occasional consumption of big game meat with lead levels as

  14. 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.

  15. 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

  16. 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

  17. 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.

  18. Lead Exposure Induces Telomere Instability in Human Cells.

    Directory of Open Access Journals (Sweden)

    Géraldine Pottier

    Full Text Available Lead (Pb is an important environmental contaminant due to its widespread use over many centuries. While it affects primarily every organ system of the body, the most pernicious effects of Pb are on the central nervous system leading to cognitive and behavioral modification. Despite decades of research, the mechanisms responsible for Pb toxicity remain poorly understood. Recent work has suggested that Pb exposure may have consequences on chromosomal integrity as it was shown that Pb exposure leads to the generation of γH2Ax foci, a well-established biomarker for DNA double stranded break (DSB formation. As the chromosomal localization of γH2Ax foci plays an important role in determining the molecular mechanism responsible for their formation, we examined the localization of Pb-induced foci with respect to telomeres. Indeed, short or dysfunctional telomeres (uncapped or damaged telomeres may be recognized as DSB by the DNA repair machinery, leading to "telomere-Induced Foci" (TIFs. In the current study, we show that while Pb exposure did not increase intra-chromosomal foci, it significantly induced TIFs, leading in some cases, to chromosomal abnormalities including telomere loss. The evidence suggests that these chromosomal abnormalities are likely due to perturbation of telomere replication, in particular on the lagging DNA strand. We propose a mechanism by which Pb exposure leads to the loss of telomere maintenance. As numerous studies have demonstrated a role for telomere maintenance in brain development and tissue homeostasis, our results suggest a possible mechanism for lead-induced neurotoxicity.

  19. Joint Estimation of Contamination, Error and Demography for Nuclear DNA from Ancient Humans

    Science.gov (United States)

    Slatkin, Montgomery

    2016-01-01

    When sequencing an ancient DNA sample from a hominin fossil, DNA from present-day humans involved in excavation and extraction will be sequenced along with the endogenous material. This type of contamination is problematic for downstream analyses as it will introduce a bias towards the population of the contaminating individual(s). Quantifying the extent of contamination is a crucial step as it allows researchers to account for possible biases that may arise in downstream genetic analyses. Here, we present an MCMC algorithm to co-estimate the contamination rate, sequencing error rate and demographic parameters—including drift times and admixture rates—for an ancient nuclear genome obtained from human remains, when the putative contaminating DNA comes from present-day humans. We assume we have a large panel representing the putative contaminant population (e.g. European, East Asian or African). The method is implemented in a C++ program called ‘Demographic Inference with Contamination and Error’ (DICE). We applied it to simulations and genome data from ancient Neanderthals and modern humans. With reasonable levels of genome sequence coverage (>3X), we find we can recover accurate estimates of all these parameters, even when the contamination rate is as high as 50%. PMID:27049965

  20. Effect of cooling on thixotropic position-sense error in human biceps muscle.

    Science.gov (United States)

    Sekihara, Chikara; Izumizaki, Masahiko; Yasuda, Tomohiro; Nakajima, Takayuki; Atsumi, Takashi; Homma, Ikuo

    2007-06-01

    Muscle temperature affects muscle thixotropy. However, it is unclear whether changes in muscle temperature affect thixotropic position-sense errors. We studied the effect of cooling on thixotropic position-sense errors induced by short-length muscle contraction (hold-short conditioning) in the biceps of 12 healthy men. After hold-short conditioning of the right biceps muscle in a cooled (5.0 degrees C) or control (36.5 degrees C) environment, subjects perceived greater extension of the conditioned forearm at 5.0 degrees C. The angle differences between the two forearms following hold-short conditioning of the right biceps muscle in normal or cooled conditions were significantly different (-3.335 +/- 1.680 degrees at 36.5 degrees C vs. -5.317 +/- 1.096 degrees at 5.0 degrees C; P=0.043). Induction of a tonic vibration reflex in the biceps muscle elicited involuntary forearm elevation, and the angular velocities of the elevation differed significantly between arms conditioned in normal and cooled environments (1.583 +/- 0.326 degrees /s at 36.5 degrees C vs. 3.100 +/- 0.555 degrees /s at 5.0 degrees C, P=0.0039). Thus, a cooled environment impairs a muscle's ability to provide positional information, potentially leading to poor muscle performance.

  1. 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

  2. The role of usability in the evaluation of accidents: human error or design flaw?

    Science.gov (United States)

    Correia, Walter; Soares, Marcelo; Barros, Marina; Campos, Fábio

    2012-01-01

    This article aims to highlight the role of consumer products companies in the heart and the extent of accidents involving these types of products, and as such undesired events take part as an agent in influencing decision making for the purchase of a product that nature on the part of consumers and users. The article demonstrates, by reference, interviews and case studies such as the development of poorly designed products and design errors of design can influence the usage behavior of users, thus leading to accidents, and also negatively affect the next image of a company. The full explanation of these types of questions aims to raise awareness, plan on a reliable usability, users and consumers in general about the safe use of consumer products, and also safeguard their rights before a legal system of consumer protection, even far away by the CDC--Code of Consumer Protection.

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

    International Nuclear Information System (INIS)

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

    1997-06-01

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

  4. Lead poisoning in China: a health and human rights crisis.

    Science.gov (United States)

    Cohen, Jane E; Amon, Joseph J

    2012-12-15

    Acute and chronic lead poisoning is occurring throughout China and is a major cause of childhood morbidity. The Chinese government's emphasis on industrial development and poverty reduction has, over the past three decades, decreased by 500 million the number of people surviving on less than one dollar per day, but has caused significant environmental degradation that threatens public health. Drawing upon in-depth interviews conducted in 2009 and 2010 with families affected by lead poisoning, environmental activists, journalists, government and civil society organization officials in Shaanxi, Henan, Hunan, and Yunnan provinces, as well as a review of scientific and Chinese media, and health and environmental legal and policy analysis, we examine the intersection of civil, political, economic, and social rights related to access to information, screening, treatment, and remediation related to lead poisoning. In-depth interviews in each province uncovered: censorship and intimidation of journalists, environmental activists, and parents seeking information about sources and prevention of lead poisoning; denial of screening for lead poisoning, often based upon arbitrary eligibility criteria; and inadequate and inappropriate treatment being promoted and provided by health facilities. Over the past decade, the Chinese government has prioritized health care and invested billions of dollars towards universal health coverage, and strengthened environmental to address industrial pollution and guarantee access to information on the environment. Yet, despite these reforms, information remains constrained and citizens seeking information and redress are sometimes arrested, in violation of Chinese and international law. Local government officials and national environmental policies continue to prioritize economic development over environmental protection. To effectively address lead poisoning requires an emphasis on prevention, and to combat industrial pollution requires

  5. Touch five factors to growing and leading a human organization

    CERN Document Server

    Maffin, Tod

    2014-01-01

    For better or worse, digital business has fundamentally changed how organizations hire, market their services, and connect with stakeholders. The problem is, in an effort to use technology to connect more effectively, we have lost the humanity - that critical person-to-person connection. This book will show you how to restore that connection.

  6. A Recent Revisit Study on the Human Error Events of Nuclear Facilities in Korea

    International Nuclear Information System (INIS)

    Lee, Y.-H.

    2016-01-01

    After Fukushima accident we have launched two new projects in Korea. One is for the development of the countermeasures for human errors in nuclear facilities, and the other is for the safety culture of nuclear power plant itself. There had happened several succeeding events that turned out to be the typical flags of the human and organizational factor issues for the safety of the other socio-technical systems as well as nuclear power plants in Korea. The second safety culture project was an ambitious development to establish an infra system utilising system dynamics, business process modeling and big-data techniques to provide effective and efficient information basis to various interest parties related to the nuclear power plants. However the project has been drastically cancelled last year without any further discussion on the original issues raised before in Korea. It may come not only from the conflicting perspectives among the different approaches to nuclear safety culture but also from the misunderstandings on the human factors for the nuclear safety.

  7. Procedures for using expert judgment to estimate human-error probabilities in nuclear power plant operations

    International Nuclear Information System (INIS)

    Seaver, D.A.; Stillwell, W.G.

    1983-03-01

    This report describes and evaluates several procedures for using expert judgment to estimate human-error probabilities (HEPs) in nuclear power plant operations. These HEPs are currently needed for several purposes, particularly for probabilistic risk assessments. Data do not exist for estimating these HEPs, so expert judgment can provide these estimates in a timely manner. Five judgmental procedures are described here: paired comparisons, ranking and rating, direct numerical estimation, indirect numerical estimation and multiattribute utility measurement. These procedures are evaluated in terms of several criteria: quality of judgments, difficulty of data collection, empirical support, acceptability, theoretical justification, and data processing. Situational constraints such as the number of experts available, the number of HEPs to be estimated, the time available, the location of the experts, and the resources available are discussed in regard to their implications for selecting a procedure for use

  8. Organizational change and human expertise in nuclear power plants: some implications for training and error prevention

    International Nuclear Information System (INIS)

    Masson, M.; Malaise, N.; Housiaux, A.; Keyser, V. de

    1993-01-01

    Reliability and safety are two very important goals, which depend on technical and organizational factors, but also on human expertise. How to ensure a safe functioning of a nuclear power plant in a changing context, and what might be the role and aspects of training and transfer of knowledge? These are the questions we shall deal with in this paper, on the basis of two field studies. The two field studies stress the needs for setting up case based training, which best ensure the acquisition of know-how. Furthermore, as shown by the second one, gaining expertise involves developing large repertoires of highly skilled, semi-routinized activities. Supporting expert operators not only should tackle problem solving activities but should thus also include the prevention of routine errors, which go along with skill acquisition. (orig.)

  9. Evolutionary enhancement of the SLIM-MAUD method of estimating human error rates

    International Nuclear Information System (INIS)

    Zamanali, J.H.; Hubbard, F.R.; Mosleh, A.; Waller, M.A.

    1992-01-01

    The methodology described in this paper assigns plant-specific dynamic human error rates (HERs) for individual plant examinations based on procedural difficulty, on configuration features, and on the time available to perform the action. This methodology is an evolutionary improvement of the success likelihood index methodology (SLIM-MAUD) for use in systemic scenarios. It is based on the assumption that the HER in a particular situation depends of the combined effects of a comprehensive set of performance-shaping factors (PSFs) that influence the operator's ability to perform the action successfully. The PSFs relate the details of the systemic scenario in which the action must be performed according to the operator's psychological and cognitive condition

  10. Gunning for accuracy: Company targets human error with 'foolproof' perforating gun

    Energy Technology Data Exchange (ETDEWEB)

    Ross, E.

    2002-12-01

    An innovative new design for a scalloped expandable perforating gun is described. The gun is manufactured in Edmonton by LRI Perforating Systems, and it aimed at reducing the chances of human error that can result in sub-optimal performance. A perforating gun is used to pierce the well's casing to allow hydrocarbons to flow into the wellbore. It consists of a carrier, a pipe with an eighth-inch thick wall that protects the explosives downhole, and an inner tube containing the explosives. The LRI system has a unique interlocking mechanism for the end plates, which are attached to either end of the thin-walled charge holder tube, in addition to other advantageous features, including a price advantage of 10 to 15 per cent. Marketing strategy is designed to interest wi reline companies that focus on vertical well applications. 1 photo.

  11. Uncorrected refractive errors.

    Science.gov (United States)

    Naidoo, Kovin S; Jaggernath, Jyoti

    2012-01-01

    Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC), were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR) Development, Service Development and Social Entrepreneurship.

  12. Uncorrected refractive errors

    Directory of Open Access Journals (Sweden)

    Kovin S Naidoo

    2012-01-01

    Full Text Available Global estimates indicate that more than 2.3 billion people in the world suffer from poor vision due to refractive error; of which 670 million people are considered visually impaired because they do not have access to corrective treatment. Refractive errors, if uncorrected, results in an impaired quality of life for millions of people worldwide, irrespective of their age, sex and ethnicity. Over the past decade, a series of studies using a survey methodology, referred to as Refractive Error Study in Children (RESC, were performed in populations with different ethnic origins and cultural settings. These studies confirmed that the prevalence of uncorrected refractive errors is considerably high for children in low-and-middle-income countries. Furthermore, uncorrected refractive error has been noted to have extensive social and economic impacts, such as limiting educational and employment opportunities of economically active persons, healthy individuals and communities. The key public health challenges presented by uncorrected refractive errors, the leading cause of vision impairment across the world, require urgent attention. To address these issues, it is critical to focus on the development of human resources and sustainable methods of service delivery. This paper discusses three core pillars to addressing the challenges posed by uncorrected refractive errors: Human Resource (HR Development, Service Development and Social Entrepreneurship.

  13. 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

  14. A study on fatigue measurement of operators for human error prevention in NPPs

    Energy Technology Data Exchange (ETDEWEB)

    Ju, Oh Yeon; Il, Jang Tong; Meiling, Luo; Hee, Lee Young [KAERI, Daejeon (Korea, Republic of)

    2012-10-15

    The identification and the analysis of individual factor of operators, which is one of the various causes of adverse effects in human performance, is not easy in NPPs. There are work types (including shift), environment, personality, qualification, training, education, cognition, fatigue, job stress, workload, etc in individual factors for the operators. Research at the Finnish Institute of Occupational Health (FIOH) reported that a 'burn out (extreme fatigue)' is related to alcohol dependent habits and must be dealt with using a stress management program. USNRC (U.S. Nuclear Regulatory Commission) developed FFD (Fitness for Duty) for improving the task efficiency and preventing human errors. 'Managing Fatigue' of 10CFR26 presented as requirements to control operator fatigue in NPPs. The committee explained that excessive fatigue is due to stressful work environments, working hours, shifts, sleep disorders, and unstable circadian rhythms. In addition, an International Labor Organization (ILO) developed and suggested a checklist to manage fatigue and job stress. In domestic, a systematic evaluation way is presented by the Final Safety Analysis Report (FSAR) chapter 18, Human Factors, in the licensing process. However, it almost focused on the interface design such as HMI (Human Machine Interface), not individual factors. In particular, because our country is in a process of the exporting the NPP to UAE, the development and setting of fatigue management technique is important and urgent to present the technical standard and FFD criteria to UAE. And also, it is anticipated that the domestic regulatory body applies the FFD program as the regulation requirement so that a preparation for that situation is required. In this paper, advanced researches are investigated to find the fatigue measurement and evaluation methods of operators in a high reliability industry. Also, this study tries to review the NRC report and discuss the causal factors and

  15. A study on fatigue measurement of operators for human error prevention in NPPs

    International Nuclear Information System (INIS)

    Ju, Oh Yeon; Il, Jang Tong; Meiling, Luo; Hee, Lee Young

    2012-01-01

    The identification and the analysis of individual factor of operators, which is one of the various causes of adverse effects in human performance, is not easy in NPPs. There are work types (including shift), environment, personality, qualification, training, education, cognition, fatigue, job stress, workload, etc in individual factors for the operators. Research at the Finnish Institute of Occupational Health (FIOH) reported that a 'burn out (extreme fatigue)' is related to alcohol dependent habits and must be dealt with using a stress management program. USNRC (U.S. Nuclear Regulatory Commission) developed FFD (Fitness for Duty) for improving the task efficiency and preventing human errors. 'Managing Fatigue' of 10CFR26 presented as requirements to control operator fatigue in NPPs. The committee explained that excessive fatigue is due to stressful work environments, working hours, shifts, sleep disorders, and unstable circadian rhythms. In addition, an International Labor Organization (ILO) developed and suggested a checklist to manage fatigue and job stress. In domestic, a systematic evaluation way is presented by the Final Safety Analysis Report (FSAR) chapter 18, Human Factors, in the licensing process. However, it almost focused on the interface design such as HMI (Human Machine Interface), not individual factors. In particular, because our country is in a process of the exporting the NPP to UAE, the development and setting of fatigue management technique is important and urgent to present the technical standard and FFD criteria to UAE. And also, it is anticipated that the domestic regulatory body applies the FFD program as the regulation requirement so that a preparation for that situation is required. In this paper, advanced researches are investigated to find the fatigue measurement and evaluation methods of operators in a high reliability industry. Also, this study tries to review the NRC report and discuss the causal factors and management

  16. 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

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

    Science.gov (United States)

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

    2015-01-01

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

  18. Spatiotemporal neural characterization of prediction error valence and surprise during reward learning in humans.

    Science.gov (United States)

    Fouragnan, Elsa; Queirazza, Filippo; Retzler, Chris; Mullinger, Karen J; Philiastides, Marios G

    2017-07-06

    Reward learning depends on accurate reward associations with potential choices. These associations can be attained with reinforcement learning mechanisms using a reward prediction error (RPE) signal (the difference between actual and expected rewards) for updating future reward expectations. Despite an extensive body of literature on the influence of RPE on learning, little has been done to investigate the potentially separate contributions of RPE valence (positive or negative) and surprise (absolute degree of deviation from expectations). Here, we coupled single-trial electroencephalography with simultaneously acquired fMRI, during a probabilistic reversal-learning task, to offer evidence of temporally overlapping but largely distinct spatial representations of RPE valence and surprise. Electrophysiological variability in RPE valence correlated with activity in regions of the human reward network promoting approach or avoidance learning. Electrophysiological variability in RPE surprise correlated primarily with activity in regions of the human attentional network controlling the speed of learning. Crucially, despite the largely separate spatial extend of these representations our EEG-informed fMRI approach uniquely revealed a linear superposition of the two RPE components in a smaller network encompassing visuo-mnemonic and reward areas. Activity in this network was further predictive of stimulus value updating indicating a comparable contribution of both signals to reward learning.

  19. 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

  20. The spontaneous replication error and the mismatch discrimination mechanisms of human DNA polymerase β

    Science.gov (United States)

    Koag, Myong-Chul; Nam, Kwangho; Lee, Seongmin

    2014-01-01

    To provide molecular-level insights into the spontaneous replication error and the mismatch discrimination mechanisms of human DNA polymerase β (polβ), we report four crystal structures of polβ complexed with dG•dTTP and dA•dCTP mismatches in the presence of Mg2+ or Mn2+. The Mg2+-bound ground-state structures show that the dA•dCTP-Mg2+ complex adopts an ‘intermediate’ protein conformation while the dG•dTTP-Mg2+ complex adopts an open protein conformation. The Mn2+-bound ‘pre-chemistry-state’ structures show that the dA•dCTP-Mn2+ complex is structurally very similar to the dA•dCTP-Mg2+ complex, whereas the dG•dTTP-Mn2+ complex undergoes a large-scale conformational change to adopt a Watson–Crick-like dG•dTTP base pair and a closed protein conformation. These structural differences, together with our molecular dynamics simulation studies, suggest that polβ increases replication fidelity via a two-stage mismatch discrimination mechanism, where one is in the ground state and the other in the closed conformation state. In the closed conformation state, polβ appears to allow only a Watson–Crick-like conformation for purine•pyrimidine base pairs, thereby discriminating the mismatched base pairs based on their ability to form the Watson–Crick-like conformation. Overall, the present studies provide new insights into the spontaneous replication error and the replication fidelity mechanisms of polβ. PMID:25200079

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

    International Nuclear Information System (INIS)

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

    1996-01-01

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

  2. 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

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

    International Nuclear Information System (INIS)

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

    2003-03-01

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

  4. Basic Characteristics of Human Erroneous Actions during Test and Maintenance Activities Leading to Unplanned Reactor Trips

    International Nuclear Information System (INIS)

    Kim, Jae Whan; Park, Jin Kyun

    2010-01-01

    Test and maintenance (T and M) activities of nuclear power plants are essential for sustaining the safety of a power plant and maintaining the reliability of plant systems and components. However, the potential of human errors during T and M activities has also the potential to induce unplanned reactor trips or power derate or making safety-related systems unavailable. According to the major incident/accident reports of nuclear power plants in Korea, contribution of human errors takes up about 20% of the total events. The previous study presents that most of human-related unplanned reactor trip events during normal power operation are associated with T and M activities (63%), which are comprised of plant maintenance activities such as a 'periodic preventive maintenance (PPM)', a 'planned maintenance (PM)' and a 'corrective maintenance (CM)'. This means that T and M activities should be a major subject for reducing the frequency of human-related unplanned reactor trips. This paper aims to introduce basic characteristics of human erroneous actions involved in the test and maintenance-induced unplanned reactor trip events that have occurred between 1986 and 2006 in Korean nuclear power plants. The basic characteristics are described by dividing human erroneous actions into planning-based errors and execution-based errors. For the events associated with planning failures, they are, firstly, classified according to existence of the work procedure and then described for what aspects of the procedure or work plan have deficiency or problem. On the other hand, for the events associated with execution failures, they are described from the aspect of external error modes

  5. 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)

  6. An Enhancement of Campaign Posters for Human Error Prevention in NPPs

    International Nuclear Information System (INIS)

    Lee, Yong Hee; Lee, Yong Hee; Kwon, Soon Il

    2010-01-01

    Accidents in high reliability systems such as nuclear power plants (NPPs) give rise to not only a loss of property and life, but also social problems. One of the most frequently used techniques to grasp the current situation for hazard factors in the NPPs is an event investigation analysis based on the INPO's Human Performance Enhancement System (HPES), and the Korean Human Performance Enhancement System (K-HPES) in Korea, respectively. There are many methods and approaches for an HE assessment that is valuable for investigating the causes of undesirable events and counter-plans to prevent their recurrence in the NPPs. They differ from each other according to the objectives of the analysis; the explanation of the event, the investigation of the causes, the allocation of the responsibility, and the establishment of the counter-plan. Event databases include their own events and information from various sources such as the IAEA, regulatory bodies, and also from the INPO and WANO. As many as 111 reactor trips have occurred in the past 5 years ('01∼'05), and 26 cases of them have occurred due to HE. The trend of human error rate didn't decrease in 2004, so the KHNP started to make efforts to decrease HEs. The KHNP created as many as 40 posters for human performance improvement in 2006. The INPO has been using a traditional form of poster; additionally, the Central Research Institute of Electric Power Industry (CRIEPI) developed a type of caution report. The caution report is comprised of a poster name, a serial number, a figure, work situations, the point at issue, and a countermeasure. The preceding posters which KHNP developed in 2006 give a message about specific information related to HE events. However, it is not enough to arouse interest in the effectiveness of the posters because most people are favorably disposed toward a simple poster with many illustrations. Therefore, we stressed the need for worker's receptiveness rather than notification of information

  7. Stable lead isotopes in environmental health with emphasis on human investigations

    International Nuclear Information System (INIS)

    Gulson, Brian

    2008-01-01

    There has been widespread use of stable lead isotopes in the earth sciences for more than 40 years focussed on the origin and age of rocks and minerals with lesser application in environmental investigations where the emphasis has been directed typically to the source of lead in environmental media such as air, water and soils. In contrast, the number of environmental health investigations focussed on humans (and primates) is limited in spite of the demonstrated utility of the approach in pioneering studies in the early 1970's. This paper reviews the status of lead isotopes in human investigations especially over the past 2 decades, the period over which most activity has taken place. Following a brief introduction to the method, examples are provided illustrating the use of lead isotopes in a wide spectrum of activities including sources and pathways of lead in diverse environments from urban to mining communities, various applications associated with pregnancy, the contribution of bone lead to blood lead including in the elderly, the half-life of lead in blood, and lead in bones and other media. A brief outline of critical research on non-human primates is also given. The lead isotope method is a powerful technique for tracing lead and could be employed more widely in human investigations

  8. 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.

  9. A bottom-up model of spatial attention predicts human error patterns in rapid scene recognition.

    Science.gov (United States)

    Einhäuser, Wolfgang; Mundhenk, T Nathan; Baldi, Pierre; Koch, Christof; Itti, Laurent

    2007-07-20

    Humans demonstrate a peculiar ability to detect complex targets in rapidly presented natural scenes. Recent studies suggest that (nearly) no focal attention is required for overall performance in such tasks. Little is known, however, of how detection performance varies from trial to trial and which stages in the processing hierarchy limit performance: bottom-up visual processing (attentional selection and/or recognition) or top-down factors (e.g., decision-making, memory, or alertness fluctuations)? To investigate the relative contribution of these factors, eight human observers performed an animal detection task in natural scenes presented at 20 Hz. Trial-by-trial performance was highly consistent across observers, far exceeding the prediction of independent errors. This consistency demonstrates that performance is not primarily limited by idiosyncratic factors but by visual processing. Two statistical stimulus properties, contrast variation in the target image and the information-theoretical measure of "surprise" in adjacent images, predict performance on a trial-by-trial basis. These measures are tightly related to spatial attention, demonstrating that spatial attention and rapid target detection share common mechanisms. To isolate the causal contribution of the surprise measure, eight additional observers performed the animal detection task in sequences that were reordered versions of those all subjects had correctly recognized in the first experiment. Reordering increased surprise before and/or after the target while keeping the target and distractors themselves unchanged. Surprise enhancement impaired target detection in all observers. Consequently, and contrary to several previously published findings, our results demonstrate that attentional limitations, rather than target recognition alone, affect the detection of targets in rapidly presented visual sequences.

  10. Isolation of low-molecular-weight lead-binding protein from human erythrocytes

    International Nuclear Information System (INIS)

    Raghavan, S.R.V.; Gonick, H.C.

    1977-01-01

    In blood, lead is mainly associated with erythrocytes and only a very small amount is found in plasma. Previously it was thought that the lead was bound to the erythrocyte cell membrane but more recently it has been observed that lead is bound primarily to the cell contents, ostensibly hemoglobin. In examining the lead-binding properties of normal human erythrocytes and those of lead-exposed industrial workers, we have found that, whereas lead binds only to hemoglobin in normal erythrocytes, there is also appreciable binding of lead to a low-molecular weight-protein in erythrocytes from lead-exposed workers. The synthesis of this protein may be induced by lead exposure. The 10,000 molecular weight protein may act as a storage site and mechanism for segregating lead in a non-toxic form

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

    Directory of Open Access Journals (Sweden)

    Mohammadreza Azhdari

    2017-03-01

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

  12. 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…

  13. 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

  14. A study on the critical factors of human error in civil aviation: An early warning management perspective in Bangladesh

    Directory of Open Access Journals (Sweden)

    Md. Salah Uddin Rajib

    2015-01-01

    Full Text Available The safety of civil aviation will be more secured if the errors in all the facets can be reduced. Like the other industrial sectors, human resource is one of the most complex and sensitive resources for the civil aviation. The error of human resources can cause fatal disasters. In these days, a good volume of researches have been conducted on the disaster of civil aviation. The researchers have identified the causes of the civil aviation disasters from various perspectives. They identified the areas where more concern is needed to reduce the disastrous impacts. This paper aims to find out the critical factors of human error in civil aviation in a developing country (Bangladesh as it is accepted that human error is one of main causes of civil aviation disasters. The paper reviews the previous research to find out the critical factors conceptually. Fuzzy analytical hierarchy process (FAHP has been used to find out the critical factors systematically. Analyses indicate that the concentration on precondition for unsafe acts (including sub-factors is required to ensure the aviation safety.

  15. Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

    Energy Technology Data Exchange (ETDEWEB)

    Koo, In Soo; Suh, S. M.; Park, G. O. (and others)

    2006-07-15

    Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'.

  16. Management and Evaluation System on Human Error, Licence Requirements, and Job-aptitude in Rail and the Other Industries

    International Nuclear Information System (INIS)

    Koo, In Soo; Suh, S. M.; Park, G. O.

    2006-07-01

    Rail system is a system that is very closely related to the public life. When an accident happens, the public using this system should be injured or even be killed. The accident that recently took place in Taegu subway system, because of the inappropriate human-side task performance, showed demonstratively how its results could turn out to be tragic one. Many studies have shown that the most cases of the accidents have occurred because of performing his/her tasks in inappropriate way. It is generally recognised that the rail system without human element could never be happened quite long time. So human element in rail system is going to be the major factor to the next tragic accident. This state of the art report studied the cases of the managements and evaluation systems related to human errors, license requirements, and job aptitudes in the areas of rail and the other industries for the purpose of improvement of the task performance of personnel which consists of an element and finally enhancement of rail safety. The human errors, license requirements, and evaluation system of the job aptitude on people engaged in agencies with close relation to rail do much for development and preservation their abilities. But due to various inside and outside factors, to some extent it may have limitations to timely reflect overall trends of society, technology, and a sense of value. Removal and control of the factors of human errors will have epochal roles in safety of the rail system through the case studies of this report. Analytical results on case studies of this report will be used in the project 'Development of Management Criteria on Human Error and Evaluation Criteria on Job-aptitude of Rail Safe-operation Personnel' which has been carried out as a part of 'Integrated R and D Program for Railway Safety'

  17. Asymmetric generalization in adaptation to target displacement errors in humans and in a neural network model.

    Science.gov (United States)

    Westendorff, Stephanie; Kuang, Shenbing; Taghizadeh, Bahareh; Donchin, Opher; Gail, Alexander

    2015-04-01

    Different error signals can induce sensorimotor adaptation during visually guided reaching, possibly evoking different neural adaptation mechanisms. Here we investigate reach adaptation induced by visual target errors without perturbing the actual or sensed hand position. We analyzed the spatial generalization of adaptation to target error to compare it with other known generalization patterns and simulated our results with a neural network model trained to minimize target error independent of prediction errors. Subjects reached to different peripheral visual targets and had to adapt to a sudden fixed-amplitude displacement ("jump") consistently occurring for only one of the reach targets. Subjects simultaneously had to perform contralateral unperturbed saccades, which rendered the reach target jump unnoticeable. As a result, subjects adapted by gradually decreasing reach errors and showed negative aftereffects for the perturbed reach target. Reach errors generalized to unperturbed targets according to a translational rather than rotational generalization pattern, but locally, not globally. More importantly, reach errors generalized asymmetrically with a skewed generalization function in the direction of the target jump. Our neural network model reproduced the skewed generalization after adaptation to target jump without having been explicitly trained to produce a specific generalization pattern. Our combined psychophysical and simulation results suggest that target jump adaptation in reaching can be explained by gradual updating of spatial motor goal representations in sensorimotor association networks, independent of learning induced by a prediction-error about the hand position. The simulations make testable predictions about the underlying changes in the tuning of sensorimotor neurons during target jump adaptation. Copyright © 2015 the American Physiological Society.

  18. 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

  19. Relevancy of human exposure via house dust to the contaminants lead and asbestos

    NARCIS (Netherlands)

    Oomen AG; Lijzen JPA; SIR; LER

    2004-01-01

    The present report addresses the issues whether house dust is likely to contribute substantially to the exposure of humans, in particular for the contaminants lead and asbestos. House dust consists for 30-70% of soil material, indicating that contaminated soil can lead to contaminated house dust. It

  20. 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)

  1. Faster Increases in Human Life Expectancy Could Lead to Slower Population Aging

    Science.gov (United States)

    2015-01-01

    Counterintuitively, faster increases in human life expectancy could lead to slower population aging. The conventional view that faster increases in human life expectancy would lead to faster population aging is based on the assumption that people become old at a fixed chronological age. A preferable alternative is to base measures of aging on people’s time left to death, because this is more closely related to the characteristics that are associated with old age. Using this alternative interpretation, we show that faster increases in life expectancy would lead to slower population aging. Among other things, this finding affects the assessment of the speed at which countries will age. PMID:25876033

  2. Minimizing human error in radiopharmaceutical preparation and administration via a bar code-enhanced nuclear pharmacy management system.

    Science.gov (United States)

    Hakala, John L; Hung, Joseph C; Mosman, Elton A

    2012-09-01

    The objective of this project was to ensure correct radiopharmaceutical administration through the use of a bar code system that links patient and drug profiles with on-site information management systems. This new combined system would minimize the amount of manual human manipulation, which has proven to be a primary source of error. The most common reason for dosing errors is improper patient identification when a dose is obtained from the nuclear pharmacy or when a dose is administered. A standardized electronic transfer of information from radiopharmaceutical preparation to injection will further reduce the risk of misadministration. Value stream maps showing the flow of the patient dose information, as well as potential points of human error, were developed. Next, a future-state map was created that included proposed corrections for the most common critical sites of error. Transitioning the current process to the future state will require solutions that address these sites. To optimize the future-state process, a bar code system that links the on-site radiology management system with the nuclear pharmacy management system was proposed. A bar-coded wristband connects the patient directly to the electronic information systems. The bar code-enhanced process linking the patient dose with the electronic information reduces the number of crucial points for human error and provides a framework to ensure that the prepared dose reaches the correct patient. Although the proposed flowchart is designed for a site with an in-house central nuclear pharmacy, much of the framework could be applied by nuclear medicine facilities using unit doses. An electronic connection between information management systems to allow the tracking of a radiopharmaceutical from preparation to administration can be a useful tool in preventing the mistakes that are an unfortunate reality for any facility.

  3. Development and validation of a novel, simple, and accurate spectrophotometric method for the determination of lead in human serum.

    Science.gov (United States)

    Shayesteh, Tavakol Heidari; Khajavi, Farzad; Khosroshahi, Abolfazl Ghafuri; Mahjub, Reza

    2016-01-01

    The determination of blood lead levels is the most useful indicator of the determination of the amount of lead that is absorbed by the human body. Various methods, like atomic absorption spectroscopy (AAS), have already been used for the detection of lead in biological fluid, but most of these methods are based on complicated, expensive, and highly instructed instruments. In this study, a simple and accurate spectroscopic method for the determination of lead has been developed and applied for the investigation of lead concentration in biological samples. In this study, a silica gel column was used to extract lead and eliminate interfering agents in human serum samples. The column was washed with deionized water. The pH was adjusted to the value of 8.2 using phosphate buffer, and then tartrate and cyanide solutions were added as masking agents. The lead content was extracted into the organic phase containing dithizone as a complexion reagent and the dithizone-Pb(II) complex was formed and approved by visible spectrophotometry at 538 nm. The recovery was found to be 84.6 %. In order to validate the method, a calibration curve involving the use of various concentration levels was calculated and proven to be linear in the range of 0.01-1.5 μg/ml, with an R (2) regression coefficient of 0.9968 by statistical analysis of linear model validation. The largest error % values were found to be -5.80 and +11.6 % for intra-day and inter-day measurements, respectively. The largest RSD % values were calculated to be 6.54 and 12.32 % for intra-day and inter-day measurements, respectively. Further, the limit of detection (LOD) was calculated to be 0.002 μg/ml. The developed method was applied to determine the lead content in the human serum of voluntary miners, and it has been proven that there is no statistically significant difference between the data provided from this novel method and the data obtained from previously studied AAS.

  4. 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

  5. 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.

  6. A statistical approach to estimating effects of performance shaping factors on human error probabilities of soft controls

    International Nuclear Information System (INIS)

    Kim, Yochan; Park, Jinkyun; Jung, Wondea; Jang, Inseok; Hyun Seong, Poong

    2015-01-01

    Despite recent efforts toward data collection for supporting human reliability analysis, there remains a lack of empirical basis in determining the effects of performance shaping factors (PSFs) on human error probabilities (HEPs). To enhance the empirical basis regarding the effects of the PSFs, a statistical methodology using a logistic regression and stepwise variable selection was proposed, and the effects of the PSF on HEPs related with the soft controls were estimated through the methodology. For this estimation, more than 600 human error opportunities related to soft controls in a computerized control room were obtained through laboratory experiments. From the eight PSF surrogates and combinations of these variables, the procedure quality, practice level, and the operation type were identified as significant factors for screen switch and mode conversion errors. The contributions of these significant factors to HEPs were also estimated in terms of a multiplicative form. The usefulness and limitation of the experimental data and the techniques employed are discussed herein, and we believe that the logistic regression and stepwise variable selection methods will provide a way to estimate the effects of PSFs on HEPs in an objective manner. - Highlights: • It is necessary to develop an empirical basis for the effects of the PSFs on the HEPs. • A statistical method using a logistic regression and variable selection was proposed. • The effects of PSFs on the HEPs of soft controls were empirically investigated. • The significant factors were identified and their effects were estimated

  7. The application of SHERPA (Systematic Human Error Reduction and Prediction Approach) in the development of compensatory cognitive rehabilitation strategies for stroke patients with left and right brain damage.

    Science.gov (United States)

    Hughes, Charmayne M L; Baber, Chris; Bienkiewicz, Marta; Worthington, Andrew; Hazell, Alexa; Hermsdörfer, Joachim

    2015-01-01

    Approximately 33% of stroke patients have difficulty performing activities of daily living, often committing errors during the planning and execution of such activities. The objective of this study was to evaluate the ability of the human error identification (HEI) technique SHERPA (Systematic Human Error Reduction and Prediction Approach) to predict errors during the performance of daily activities in stroke patients with left and right hemisphere lesions. Using SHERPA we successfully predicted 36 of the 38 observed errors, with analysis indicating that the proportion of predicted and observed errors was similar for all sub-tasks and severity levels. HEI results were used to develop compensatory cognitive strategies that clinicians could employ to reduce or prevent errors from occurring. This study provides evidence for the reliability and validity of SHERPA in the design of cognitive rehabilitation strategies in stroke populations.

  8. 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.

  9. Lead bullet fragments in venison from rifle-killed deer: potential for human dietary exposure.

    Directory of Open Access Journals (Sweden)

    W Grainger Hunt

    Full Text Available Human consumers of wildlife killed with lead ammunition may be exposed to health risks associated with lead ingestion. This hypothesis is based on published studies showing elevated blood lead concentrations in subsistence hunter populations, retention of ammunition residues in the tissues of hunter-killed animals, and systemic, cognitive, and behavioral disorders associated with human lead body burdens once considered safe. Our objective was to determine the incidence and bioavailability of lead bullet fragments in hunter-killed venison, a widely-eaten food among hunters and their families. We radiographed 30 eviscerated carcasses of White-tailed Deer (Odocoileus virginianus shot by hunters with standard lead-core, copper-jacketed bullets under normal hunting conditions. All carcasses showed metal fragments (geometric mean = 136 fragments, range = 15-409 and widespread fragment dispersion. We took each carcass to a separate meat processor and fluoroscopically scanned the resulting meat packages; fluoroscopy revealed metal fragments in the ground meat packages of 24 (80% of the 30 deer; 32% of 234 ground meat packages contained at least one fragment. Fragments were identified as lead by ICP in 93% of 27 samples. Isotope ratios of lead in meat matched the ratios of bullets, and differed from background lead in bone. We fed fragment-containing venison to four pigs to test bioavailability; four controls received venison without fragments from the same deer. Mean blood lead concentrations in pigs peaked at 2.29 microg/dL (maximum 3.8 microg/dL 2 days following ingestion of fragment-containing venison, significantly higher than the 0.63 microg/dL averaged by controls. We conclude that people risk exposure to bioavailable lead from bullet fragments when they eat venison from deer killed with standard lead-based rifle bullets and processed under normal procedures. At risk in the U.S. are some ten million hunters, their families, and low

  10. Distinguishing science from pseudoscience in school psychology: science and scientific thinking as safeguards against human error.

    Science.gov (United States)

    Lilienfeld, Scott O; Ammirati, Rachel; David, Michal

    2012-02-01

    Like many domains of professional psychology, school psychology continues to struggle with the problem of distinguishing scientific from pseudoscientific and otherwise questionable clinical practices. We review evidence for the scientist-practitioner gap in school psychology and provide a user-friendly primer on science and scientific thinking for school psychologists. Specifically, we (a) outline basic principles of scientific thinking, (b) delineate widespread cognitive errors that can contribute to belief in pseudoscientific practices within school psychology and allied professions, (c) provide a list of 10 key warning signs of pseudoscience, illustrated by contemporary examples from school psychology and allied disciplines, and (d) offer 10 user-friendly prescriptions designed to encourage scientific thinking among school psychology practitioners and researchers. We argue that scientific thinking, although fallible, is ultimately school psychologists' best safeguard against a host of errors in thinking. Copyright © 2011 Society for the Study of School Psychology. Published by Elsevier Ltd. All rights reserved.

  11. A decision support system and rule-based algorithm to augment the human interpretation of the 12-lead electrocardiogram.

    Science.gov (United States)

    Cairns, Andrew W; Bond, Raymond R; Finlay, Dewar D; Guldenring, Daniel; Badilini, Fabio; Libretti, Guido; Peace, Aaron J; Leslie, Stephen J

    The 12-lead Electrocardiogram (ECG) has been used to detect cardiac abnormalities in the same format for more than 70years. However, due to the complex nature of 12-lead ECG interpretation, there is a significant cognitive workload required from the interpreter. This complexity in ECG interpretation often leads to errors in diagnosis and subsequent treatment. We have previously reported on the development of an ECG interpretation support system designed to augment the human interpretation process. This computerised decision support system has been named 'Interactive Progressive based Interpretation' (IPI). In this study, a decision support algorithm was built into the IPI system to suggest potential diagnoses based on the interpreter's annotations of the 12-lead ECG. We hypothesise semi-automatic interpretation using a digital assistant can be an optimal man-machine model for ECG interpretation. To improve interpretation accuracy and reduce missed co-abnormalities. The Differential Diagnoses Algorithm (DDA) was developed using web technologies where diagnostic ECG criteria are defined in an open storage format, Javascript Object Notation (JSON), which is queried using a rule-based reasoning algorithm to suggest diagnoses. To test our hypothesis, a counterbalanced trial was designed where subjects interpreted ECGs using the conventional approach and using the IPI+DDA approach. A total of 375 interpretations were collected. The IPI+DDA approach was shown to improve diagnostic accuracy by 8.7% (although not statistically significant, p-value=0.1852), the IPI+DDA suggested the correct interpretation more often than the human interpreter in 7/10 cases (varying statistical significance). Human interpretation accuracy increased to 70% when seven suggestions were generated. Although results were not found to be statistically significant, we found; 1) our decision support tool increased the number of correct interpretations, 2) the DDA algorithm suggested the correct

  12. Human error and the associated recovery probabilities for soft control being used in the advanced MCRs of NPPs

    International Nuclear Information System (INIS)

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

    2016-01-01

    Highlights: • The operation environment of MCRs in NPPs has changed by adopting digital HSIs. • Most current HRA databases are not explicitly designed to deal with digital HSI. • Empirical analysis for new HRA DB under an advanced MCR mockup are carried. • It is expected that the results can be used for advanced MCR HRA. - 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 studies were focused on considering the conventional Main Control Room (MCR) environment. However, the operating environment of MCRs in NPPs has changed with the adoption of new human-system interfaces (HSI) largely based on up-to-date digital 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 because operating actions in advanced MCRs are performed by soft control. Due to the difference in interfaces between soft control and hardwired conventional controls, different HEP should be used in the HRA for advanced MCRs. Unfortunately, most current HRA databases deal with operations in conventional MCRs and are not explicitly designed to deal with digital Human System Interface (HSI). For this reason, empirical human error and the associated error recovery probabilities were collected from the mockup of an advanced MCR equipped with soft controls. To this end, small-scaled experiments are conducted with 48 graduated students in the department of nuclear engineering in Korea Advanced Institute of Science and Technology (KAIST) are participated, and accident scenarios are designed with respect to the typical Design Basis Accidents (DBAs) in NPPs, such as Steam Generator Tube Rupture

  13. Long-term human exposure to lead from different media and intake pathways.

    Science.gov (United States)

    Pizzol, Massimo; Thomsen, Marianne; Andersen, Mikael Skou

    2010-10-15

    Lead (Pb) is well known as an environmental pollutant: it can accumulate in various media, so actual lead exposure reflects both historical and present contaminations. Two main challenges then emerge: obtaining updated information to gain an overall picture of the sources of exposure, and predicting the resulting internal body exposure levels and effects that occur under long-term exposure conditions. In this paper, a modeling approach is used to meet these challenges with reference to Danish exposure conditions. Levels of lead content in various media have been coupled with data for lead intake and absorption in the human body, for both children and adults. An age-dependent biokinetic model allows then for determination of the blood lead levels resulting from chronic exposure. The study shows that the actual intake of lead is up to 27% of the Provisional Tolerable Daily Intake (PTDI) for children and around 8% for adults. It is confirmed that the critical route of exposure is via ingestion, accounting for 99% of total lead intake, while inhalation contributes only to 1% of total lead intake. The resulting lead levels in the blood after 2 years of exposure to actual contamination conditions have been estimated as up to 2.2μg/dl in children and almost 1μg/dl in adults. Impacts from lead can occur even at such levels. The role of historical and present sources to lead in the environment is discussed, and, for specific child and adult exposure scenarios, external-internal concentration relationships for the direct linkage between lead in environmental media and resulting concentrations of lead in blood are then presented. Copyright © 2010 Elsevier B.V. All rights reserved.

  14. Intracellular free calcium concentration and calcium transport in human erythrocytes of lead-exposed workers

    International Nuclear Information System (INIS)

    Quintanar-Escorza, M.A.; Gonzalez-Martinez, M.T.; Navarro, L.; Maldonado, M.; Arevalo, B.; Calderon-Salinas, J.V.

    2007-01-01

    Erythrocytes are the route of lead distribution to organs and tissues. The effect of lead on calcium homeostasis in human erythrocytes and other excitable cells is not known. In the present work we studied the effect of lead intoxication on the uptake and efflux (measured as (Ca 2+ -Mg 2+ )-ATPase activity) of calcium were studied in erythrocytes obtained from lead-exposed workers. Blood samples were taken from 15 workers exposed to lead (blood lead concentration 74.4 ± 21.9 μg/dl) and 15 non-exposed workers (9.9 ± 2 μg/dl). In erythrocytes of lead-exposed workers, the intracellular free calcium was 79 ± 13 nM, a significantly higher concentration (ANOVA, P 2+ -Mg 2+ )-ATPase activity. Lipid peroxidation was 1.7-fold higher in erythrocytes of lead-exposed workers as compared with control. The alteration on calcium equilibrium in erythrocytes is discussed in light of the toxicological effects in lead-exposed workers

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

    International Nuclear Information System (INIS)

    Miyazaki, Takamasa

    2007-01-01

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

  16. Quality Assurance Analysis of a Large Multicenter Practice: Does Increased Complexity of Intensity-Modulated Radiotherapy Lead to Increased Error Frequency?

    International Nuclear Information System (INIS)

    Olson, Adam C.; Wegner, Rodney E.; Scicutella, Carol; Heron, Dwight E.; Greenberger, Joel S.; Huq, M. Saiful; Bednarz, Gregory; Flickinger, John C.

    2012-01-01

    Purpose: Error reduction is an important concern in clinical medicine. Intensity-modulated radiotherapy (IMRT) is an important advancement in radiation oncology that increases the complexity of treatment, potentially increasing the error risk. We studied the frequency and severity of errors in a large multicenter practice to ascertain the impact of quality improvement interventions over time, IMRT, and type of practice. Methods and Materials: We analyzed prospective data from three academic and 16 community practice sites with 24,775 courses of radiotherapy (9,210 IMRT courses and 15,565 non-IMRT) between January 2006 and December 2009. All IMRT treatment was performed using one centralized dose planning center for all sites. Results: We prospectively identified various errors or potential errors in 0.14 % vs. 0.40 % of the IMRT vs. non-IMRT courses (13/9,210 vs. 62/15,565, p = 0.0004) and excluding potential errors: 0.03 % for IMRT vs. 0.21% for non-IMRT. We developed the Clinical Radiotherapy Error Severity Scale (CRESS) to classify error severity from 1 to 10, with 1 to 3 for potential or completely correctable errors, 4 to 5 for dose variations 5%. Multivariate analyses of CRESS values, severity >4, and any error (including potential) correlated significantly reduced errors with IMRT (p = 0.0001–0.0024) but found no significant difference between the academic and community practice sites and no change in error frequency over time despite implementation of 39 system-wide policy changes by the centralized quality improvement committee. Conclusions: Despite the increase in complexity with IMRT compared with conventional radiotherapy, it can be delivered with reduced error frequency.

  17. The Error Is the Clue: Breakdown In Human-Machine Interaction

    National Research Council Canada - National Science Library

    Martinovsky, Bilyana; Traum, David

    2006-01-01

    .... Human reactions to these irritating features typically appear in the following order: tiredness, tolerance, anger, confusion, irony, humor, exhaustion, uncertainty, lack of desire to communicate. The studied features of human expressions of irritation in nonface- to-face interaction are: intonation, emphatic speech, elliptic speech, speed of speech, extra-linguistic signs, speed of verbal action, and overlap.

  18. Lead-poisoned wildfowl in Spain: a significant threat for human consumers.

    Science.gov (United States)

    Guitart, Raimon; Serratosa, Jordi; Thomas, Vernon G

    2002-12-01

    Each year, 1.2 million Spanish hunters and shooters discharge 6,000 t of lead shot, of which 30-50 t are deposited in wetlands of this European country. Waterfowl may accidentally ingest lead pellets in these aquatic habitats and become fatally lead poisoned. It has been estimated that 50,000 birds die from this cause in Spain each year, but many more are chronically affected. Most of them are species that can be hunted legally, and the lead toxicosis enhances their susceptibility to being killed by hunting. Consequently, about 30,000 waterfowl hunters and their families, especially children, are at risk from secondary lead ingestion from these poisoned birds. The consumption of a single liver (often eaten in Spain) from any waterfowl shot in this country may result in the direct uptake of 0.01-2.3 mg of lead in 40.4% of cases. This is based on the percentage of 411 analyzed waterfowl having liver lead contents over 0.5 mg kg(-1) wet weight, the maximum lead level in poultry offal that current EU regulations permit. Therefore, health management authorities should draw urgent attention to this environmental problem that presents such an established risk to human health.

  19. Hepatic glucose output in humans measured with labeled glucose to reduce negative errors

    International Nuclear Information System (INIS)

    Levy, J.C.; Brown, G.; Matthews, D.R.; Turner, R.C.

    1989-01-01

    Steele and others have suggested that minimizing changes in glucose specific activity when estimating hepatic glucose output (HGO) during glucose infusions could reduce non-steady-state errors. This approach was assessed in nondiabetic and type II diabetic subjects during constant low dose [27 mumol.kg ideal body wt (IBW)-1.min-1] glucose infusion followed by a 12 mmol/l hyperglycemic clamp. Eight subjects had paired tests with and without labeled infusions. Labeled infusion was used to compare HGO in 11 nondiabetic and 15 diabetic subjects. Whereas unlabeled infusions produced negative values for endogenous glucose output, labeled infusions largely eliminated this error and reduced the dependence of the Steele model on the pool fraction in the paired tests. By use of labeled infusions, 11 nondiabetic subjects suppressed HGO from 10.2 +/- 0.6 (SE) fasting to 0.8 +/- 0.9 mumol.kg IBW-1.min-1 after 90 min of glucose infusion and to -1.9 +/- 0.5 mumol.kg IBW-1.min-1 after 90 min of a 12 mmol/l glucose clamp, but 15 diabetic subjects suppressed only partially from 13.0 +/- 0.9 fasting to 5.7 +/- 1.2 at the end of the glucose infusion and 5.6 +/- 1.0 mumol.kg IBW-1.min-1 in the clamp (P = 0.02, 0.002, and less than 0.001, respectively)

  20. The Measure of Human Error: Direct and Indirect Performance Shaping Factors

    Energy Technology Data Exchange (ETDEWEB)

    Ronald L. Boring; Candice D. Griffith; Jeffrey C. Joe

    2007-08-01

    The goal of performance shaping factors (PSFs) is to provide measures to account for human performance. PSFs fall into two categories—direct and indirect measures of human performance. While some PSFs such as “time to complete a task” are directly measurable, other PSFs, such as “fitness for duty,” can only be measured indirectly through other measures and PSFs, such as through fatigue measures. This paper explores the role of direct and indirect measures in human reliability analysis (HRA) and the implications that measurement theory has on analyses and applications using PSFs. The paper concludes with suggestions for maximizing the reliability and validity of PSFs.

  1. Observed Human Actions, and Not Mechanical Actions, Induce Searching Errors in Infants

    Directory of Open Access Journals (Sweden)

    Yusuke Moriguchi

    2012-01-01

    Full Text Available Recent neurophysiological studies have shown that several human brain regions involved in executing actions are activated by merely observing such actions via a human, and not by a mechanical hand. At a behavioral level, observing a human’s movements, but not those of a robot, significantly interferes with ongoing executed movements. However, it is unclear whether the biological tuning in the observation/execution matching system are functional during infancy. The present study examines whether a human’s actions, and not a mechanical action, influence infants’ execution of the same actions due to the observation/execution matching system. Twelve-month-old infants were given a searching task. In the tasks, infants observed an object hidden at location A, after which either a human hand (human condition or a mechanical one (mechanical condition searched the object correctly. Next, the object was hidden at location B and infants were allowed to search the object. We examined whether infants searched the object at location B correctly. The results revealed that infants in the human condition were more likely to search location A than those in the mechanical condition. Moreover, the results suggested that infants’ searching behaviors were affected by their observations of the same actions by a human, but not a mechanical hand. Thus, it may be concluded that the observation/execution matching system may be biologically tuned during infancy.

  2. [To consider negative viral loads below the limit of quantification can lead to errors in the diagnosis and treatment of hepatitis C virus infection].

    Science.gov (United States)

    Acero Fernández, Doroteo; Ferri Iglesias, María José; López Nuñez, Carme; Louvrie Freire, René; Aldeguer Manté, Xavier

    2013-01-01

    For years many clinical laboratories have routinely classified undetectable and unquantifiable levels of hepatitis C virus RNA (HCV-RNA) determined by RT-PCR as below limit of quantification (BLOQ). This practice might result in erroneous clinical decisions. To assess the frequency and clinical relevance of assuming that samples that are BLOQ are negative. We performed a retrospective analysis of RNA determinations performed between 2009 and 2011 (Cobas/Taqman, lower LOQ: 15 IU/ml). We distinguished between samples classified as «undetectable» and those classified as «<1.50E+01IU/mL» (BLOQ). We analyzed 2.432 HCV-RNA measurements in 1.371 patients. RNA was BLOQ in 26 samples (1.07%) from 23 patients (1.68%). BLOQ results were highly prevalent among patients receiving Peg-Riba: 23 of 216 samples (10.6%) from 20 of 88 patients receiving treatment (22.7%). The clinical impact of BLOQ RNA samples was as follows: a) 2 patients initially considered to have negative results subsequently showed quantifiable RNA; b) 8 of 9 patients (88.9%) with BLOQ RNA at week 4 of treatment later showed sustained viral response; c) 3 patients with BLOQ RNA at weeks 12 and 48 of treatment relapsed; d) 4 patients with BLOQ RNA at week 24 and/or later had partial or breakthrough treatment responses, and e) in 5 patients the impact were null or could not be ascertained. This study suggests that BLOQ HCV-RNA indicates viremia and that equating a BLOQ result with a negative result can lead to treatment errors. BLOQ results are highly prevalent in on-treatment patients. The results of HCV-RNA quantification should be classified clearly, distinguishing between undetectable levels and levels that are BLOQ. Copyright © 2013 Elsevier España, S.L. and AEEH y AEG. All rights reserved.

  3. Using a structured morbidity and mortality meeting to understand the contribution of human error to adverse surgical events in a South African regional hospital.

    Science.gov (United States)

    Clarke, Damian L; Furlong, Heidi; Laing, Grant L; Aldous, Colleen; Thomson, Sandie Rutherford

    2013-10-22

    Several authors have suggested that the traditional surgical morbidity and mortality meeting be developed as a tool to identify surgical errors and turn them into learning opportunities for staff. We report our experience with these meetings. A structured template was developed for each morbidity and mortality meeting. We used a grid to analyse mortality and classify the death as: (i) death expected/death unexpected; and (ii) death unpreventable/death preventable. Individual cases were then analysed using a combination of error taxonomies. During the period June - December 2011, a total of 400 acute admissions (195 trauma and 205 non-trauma) were managed at Edendale Hospital, Pietermaritzburg, South Africa. During this period, 20 morbidity and mortality meetings were held, at which 30 patients were discussed. There were 10 deaths, of which 5 were unexpected and potentially avoidable. A total of 43 errors were recognised, all in the domain of the acute admissions ward. There were 33 assessment failures, 5 logistical failures, 5 resuscitation failures, 16 errors of execution and 27 errors of planning. Seven patients experienced a number of errors, of whom 5 died. Error theory successfully dissected out the contribution of error to adverse events in our institution. Translating this insight into effective strategies to reduce the incidence of error remains a challenge. Using the examples of error identified at the meetings as educational cases may help with initiatives that directly target human error in trauma care.

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

    Directory of Open Access Journals (Sweden)

    M. Omidvari

    2015-09-01

    .Conclusion: According to the obtained results, it can be concluded that human errors can be greatly reduced by training, right choice of workers with regard to the type of occupations, and provision of appropriate safety conditions in the work place.

  5. Mapping the Pairwise Choices Leading from Pluripotency to Human Bone, Heart, and Other Mesoderm Cell Types.

    Science.gov (United States)

    Loh, Kyle M; Chen, Angela; Koh, Pang Wei; Deng, Tianda Z; Sinha, Rahul; Tsai, Jonathan M; Barkal, Amira A; Shen, Kimberle Y; Jain, Rajan; Morganti, Rachel M; Shyh-Chang, Ng; Fernhoff, Nathaniel B; George, Benson M; Wernig, Gerlinde; Salomon, Rachel E A; Chen, Zhenghao; Vogel, Hannes; Epstein, Jonathan A; Kundaje, Anshul; Talbot, William S; Beachy, Philip A; Ang, Lay Teng; Weissman, Irving L

    2016-07-14

    Stem-cell differentiation to desired lineages requires navigating alternating developmental paths that often lead to unwanted cell types. Hence, comprehensive developmental roadmaps are crucial to channel stem-cell differentiation toward desired fates. To this end, here, we map bifurcating lineage choices leading from pluripotency to 12 human mesodermal lineages, including bone, muscle, and heart. We defined the extrinsic signals controlling each binary lineage decision, enabling us to logically block differentiation toward unwanted fates and rapidly steer pluripotent stem cells toward 80%-99% pure human mesodermal lineages at most branchpoints. This strategy enabled the generation of human bone and heart progenitors that could engraft in respective in vivo models. Mapping stepwise chromatin and single-cell gene expression changes in mesoderm development uncovered somite segmentation, a previously unobservable human embryonic event transiently marked by HOPX expression. Collectively, this roadmap enables navigation of mesodermal development to produce transplantable human tissue progenitors and uncover developmental processes. VIDEO ABSTRACT. Copyright © 2016 Elsevier Inc. All rights reserved.

  6. [Effects of lead exposure on the human body and health implications].

    Science.gov (United States)

    Moreira, Fátima Ramos; Moreira, Josino Costa

    2004-02-01

    To review the literature concerning the risks associated with exposure to lead and lead compounds, especially in children and in populations that are occupationally exposed. Using "chumbo" [lead] and "efeitos" [effects] as search terms, two large databases, namely PubMed (United States National Library of Medicine) and LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde [Latin American and Caribbean Literature in the Health Sciences]), were searched for studies on lead toxicity from 1988 to 2002. Other sources used to conduct the search include the web page of the United States Agency for Toxic Substances and Disease Registry, in Atlanta, Georgia, and the library of the Toxicology Laboratory of the Center for Workers' Health and Human Ecology at the National School of Public Health [Centro de Estudos da Saúde de Trabalhador e Ecologia Humana, Escola Nacional de Saúde Pública], Fundação Oswaldo Cruz, Rio de Janeiro, Brazil. The toxic effects of lead and lead compounds have been extensively studied for over a century. In recent years, epidemiologic studies have focused primarily on the neurotoxic effects of lead on children, particularly in terms of impaired intellectual ability and behavioral problems. However, there is still insufficient information on the mechanisms of action that account for such toxicity. More in-depth studies are also needed on the effects of lead exposure on bone, the central nervous system, the cardiovascular system, the kidneys, the liver, the male and female reproductive systems, and the endocrine system. The potential teratogenicity and carcinogenicity of lead, as well as its effect on pregnancy outcomes and neonatal growth and development, also require further study.

  7. Lead (Pb) Isotope Baselines for Studies of Ancient Human Migration and Trade in the Maya Region

    Science.gov (United States)

    Kamenov, George D.; Gilli, Adrian; Hodell, David A.; Emery, Kitty F.; Brenner, Mark; Krigbaum, John

    2016-01-01

    We examined the potential use of lead (Pb) isotopes to source archaeological materials from the Maya region of Mesoamerica. The main objectives were to determine if: 1) geologic terrains throughout the Maya area exhibit distinct lead isotope ratios (206Pb/204Pb, 207Pb/204Pb, and 208Pb/204Pb), and 2) a combination of lead and strontium ratios can enhance sourcing procedures in the Mesoamerica region. We analyzed 60 rock samples for lead isotope ratios and a representative subset of samples for lead, uranium, and thorium concentrations across the Maya region, including the Northern Lowlands of the Mexican Yucatan Peninsula, the Southern Lowlands of Guatemala and Belize, the Volcanic Highlands, the Belizean Maya Mountains, and the Metamorphic Province/Motagua Valley. Although there is some overlap within certain sub-regions, particularly the geologically diverse Metamorphic Province, lead isotopes can be used to distinguish between the Northern Lowlands, the Southern Lowlands, and the Volcanic Highlands. The distinct lead isotope ratios in the sub-regions are related to the geology of the Maya area, exhibiting a general trend in the lowlands of geologically younger rocks in the north to older rocks in the south, and Cenozoic volcanic rocks in the southern highlands. Combined with other sourcing techniques such as strontium (87Sr/86Sr) and oxygen (δ18O), a regional baseline for lead isotope ratios can contribute to the development of lead isoscapes in the Maya area, and may help to distinguish among geographic sub-regions at a finer scale than has been previously possible. These isotope baselines will provide archaeologists with an additional tool to track the origin and movement of ancient humans and artifacts across this important region. PMID:27806065

  8. Lead (Pb) Isotope Baselines for Studies of Ancient Human Migration and Trade in the Maya Region.

    Science.gov (United States)

    Sharpe, Ashley E; Kamenov, George D; Gilli, Adrian; Hodell, David A; Emery, Kitty F; Brenner, Mark; Krigbaum, John

    2016-01-01

    We examined the potential use of lead (Pb) isotopes to source archaeological materials from the Maya region of Mesoamerica. The main objectives were to determine if: 1) geologic terrains throughout the Maya area exhibit distinct lead isotope ratios (206Pb/204Pb, 207Pb/204Pb, and 208Pb/204Pb), and 2) a combination of lead and strontium ratios can enhance sourcing procedures in the Mesoamerica region. We analyzed 60 rock samples for lead isotope ratios and a representative subset of samples for lead, uranium, and thorium concentrations across the Maya region, including the Northern Lowlands of the Mexican Yucatan Peninsula, the Southern Lowlands of Guatemala and Belize, the Volcanic Highlands, the Belizean Maya Mountains, and the Metamorphic Province/Motagua Valley. Although there is some overlap within certain sub-regions, particularly the geologically diverse Metamorphic Province, lead isotopes can be used to distinguish between the Northern Lowlands, the Southern Lowlands, and the Volcanic Highlands. The distinct lead isotope ratios in the sub-regions are related to the geology of the Maya area, exhibiting a general trend in the lowlands of geologically younger rocks in the north to older rocks in the south, and Cenozoic volcanic rocks in the southern highlands. Combined with other sourcing techniques such as strontium (87Sr/86Sr) and oxygen (δ18O), a regional baseline for lead isotope ratios can contribute to the development of lead isoscapes in the Maya area, and may help to distinguish among geographic sub-regions at a finer scale than has been previously possible. These isotope baselines will provide archaeologists with an additional tool to track the origin and movement of ancient humans and artifacts across this important region.

  9. Human Error Probabilites (HEPs) for generic tasks and Performance Shaping Factors (PSFs) selected for railway operations

    DEFF Research Database (Denmark)

    Thommesen, Jacob; Andersen, Henning Boje

    This report describes an HRA (Human Reliability Assessment) of six generic tasks and four Perfor-mance Shaping Factors (PSFs) targeted at railway operations commissioned by Banedanmark. The selection and characterization of generic tasks and PSFs are elaborated by DTU Management in close...

  10. Substituted 2-Phenyl-Imidazopyridines: A New Class of Drug Leads for Human African Trypanosomiasis

    Science.gov (United States)

    Tatipaka, Hari Babu; Gillespie, J. Robert; Chatterjee, Arnab K.; Norcross, Neil R.; Hulverson, Matthew A.; Ranade, Ranae M.; Nagendar, Pendem; Creason, Sharon A.; McQueen, Joshua; Duster, Nicole A.; Nagle, Advait; Supek, Frantisek; Molteni, Valentina; Wenzler, Tanja; Brun, Reto; Glynne, Richard; Buckner, Frederick S.; Gelb, Michael H.

    2014-01-01

    A phenotypic screen of a compound library for antiparasitic activity on Trypanosoma brucei, the causative agent of human African trypanosomiasis, led to the identification of substituted 2-(3-aminophenyl) oxazolopyridines as a starting point for hit-to-lead medicinal chemistry. A total of 110 analogues were prepared, which led to the identification of 64, a substituted 2-(3-aminophenyl) imidazopyridine. This compound showed antiparasitic activity in vitro with an EC50 of 2 nM and displayed reasonable drug-like properties when tested in a number of in vitro assays. The compound was orally bioavailable and displayed good plasma and brain exposure in mice. Compound 64 cured mice infected with Trypanosoma brucei when dosed orally down to 2.5 mg/kg. Given its potent anti-parasitic properties and its ease of synthesis, compound 64 represents a new lead for the development of drugs to treat human African trypanosomiasis. PMID:24354316

  11. Analysis of Human Errors in Industrial Incidents and Accidents for Improvement of Work Safety

    DEFF Research Database (Denmark)

    Leplat, J.; Rasmussen, Jens

    1984-01-01

    Methods for the analysis of work accidents are discussed, and a description is given of the use of a causal situation analysis in terms of a 'variation tree' in order to explain the course of events of the individual cases and to identify possible improvements. The difficulties in identifying...... 'causes' of accidents are discussed, and it is proposed to analyze accident reports with the specific aim of identifying the potential for future improvements rather than causes of past events. In contrast to traditional statistical analysis of work accident data, which typically give very general...... recommendations, the method proposed identifies very explicit countermeasures. Improvements require a change in human decisions during equipment design, work planning, or the execution itself. The use of a model of human behavior drawing a distinction between automated skill-based behavior, rule-based 'know...

  12. A nucleotide-analogue-induced gain of function corrects the error-prone nature of human DNA polymerase iota.

    Science.gov (United States)

    Ketkar, Amit; Zafar, Maroof K; Banerjee, Surajit; Marquez, Victor E; Egli, Martin; Eoff, Robert L

    2012-06-27

    Y-family DNA polymerases participate in replication stress and DNA damage tolerance mechanisms. The properties that allow these enzymes to copy past bulky adducts or distorted template DNA can result in a greater propensity for them to make mistakes. Of the four human Y-family members, human DNA polymerase iota (hpol ι) is the most error-prone. In the current study, we elucidate the molecular basis for improving the fidelity of hpol ι through use of the fixed-conformation nucleotide North-methanocarba-2'-deoxyadenosine triphosphate (N-MC-dATP). Three crystal structures were solved of hpol ι in complex with DNA containing a template 2'-deoxythymidine (dT) paired with an incoming dNTP or modified nucleotide triphosphate. The ternary complex of hpol ι inserting N-MC-dATP opposite dT reveals that the adenine ring is stabilized in the anti orientation about the pseudo-glycosyl torsion angle, which mimics precisely the mutagenic arrangement of dGTP:dT normally preferred by hpol ι. The stabilized anti conformation occurs without notable contacts from the protein but likely results from constraints imposed by the bicyclo[3.1.0]hexane scaffold of the modified nucleotide. Unmodified dATP and South-MC-dATP each adopt syn glycosyl orientations to form Hoogsteen base pairs with dT. The Hoogsteen orientation exhibits weaker base-stacking interactions and is less catalytically favorable than anti N-MC-dATP. Thus, N-MC-dATP corrects the error-prone nature of hpol ι by preventing the Hoogsteen base-pairing mode normally observed for hpol ι-catalyzed insertion of dATP opposite dT. These results provide a previously unrecognized means of altering the efficiency and the fidelity of a human translesion DNA polymerase.

  13. A nucleotide analogue induced gain of function corrects the error-prone nature of human DNA polymerase iota

    Science.gov (United States)

    Ketkar, Amit; Zafar, Maroof K.; Banerjee, Surajit; Marquez, Victor E.; Egli, Martin; Eoff, Robert L

    2012-01-01

    Y-family DNA polymerases participate in replication stress and DNA damage tolerance mechanisms. The properties that allow these enzymes to copy past bulky adducts or distorted template DNA can result in a greater propensity for them to make mistakes. Of the four human Y-family members, human DNA polymerase iota (hpol ι) is the most error-prone. In the current study, we elucidate the molecular basis for improving the fidelity of hpol ι through use of the fixed-conformation nucleotide North-methanocarba-2′-deoxyadenosine triphosphate (N-MC-dATP). Three crystal structures were solved of hpol ι in complex with DNA containing a template 2′-deoxythymidine (dT) paired with an incoming dNTP or modified nucleotide triphosphate. The ternary complex of hpol ι inserting N-MC-dATP opposite dT reveals that the adenine ring is stabilized in the anti orientation about the pseudo-glycosyl torsion angle (χ), which mimics precisely the mutagenic arrangement of dGTP:dT normally preferred by hpol ι. The stabilized anti conformation occurs without notable contacts from the protein but likely results from constraints imposed by the bicyclo[3.1.0]hexane scaffold of the modified nucleotide. Unmodified dATP and South-MC-dATP each adopt syn glycosyl orientations to form Hoogsteen base pairs with dT. The Hoogsteen orientation exhibits weaker base stacking interactions and is less catalytically favorable than anti N-MC-dATP. Thus, N-MC-dATP corrects the error-prone nature of hpol ι by preventing the Hoogsteen base-pairing mode normally observed for hpol ι-catalyzed insertion of dATP opposite dT. These results provide a previously unrecognized means of altering the efficiency and the fidelity of a human translesion DNA polymerase. PMID:22632140

  14. The Pb isotopic record of historical to modern human lead exposure

    International Nuclear Information System (INIS)

    Kamenov, George D.; Gulson, Brian L.

    2014-01-01

    Human teeth and bones incorporate trace amounts of lead (Pb) from the local environment during growth and remodeling. Anthropogenic activities have caused changes in the natural Pb isotopic background since historical times and this is reflected in the Pb isotopes of historical European teeth. Lead mining and use increased exponentially during the last century and the isotopic compositions of modern human teeth reflect the modern anthropogenic Pb. USA teeth show the most radiogenic Pb and Australian teeth show the least radiogenic Pb, a result of different Pb ores used in the two regions. During the last century the Australian Pb was exported to Europe, Asia, South America, and Africa, resulting in swamping of the local environmental Pb signal by the imported Pb. As a result, the modern human teeth in Europe show a significant drop to lower isotopic values compared with historical times. Similarly, modern human teeth in other regions of the world show similar Pb isotopic ratios to modern European teeth reflecting the Pb imports. The specific pattern of human Pb exposure allows us to use the Pb isotopic signal recorded in the skeleton as a geo-referencing tool. As historical European teeth show a distinct Pb signal, we can identify early European skeletal remains in the New World and likely elsewhere. In modern forensic investigations we can discriminate to some extent Eastern Europeans from Western and Northern Europeans. Australians can be identified to some extent in any region in the world, although there is some overlap with Western European individuals. Lead isotopes can be used to easily identify foreigners in the USA, as modern USA teeth are distinct from any other region of the world. By analogy, USA individuals can be identified virtually in any other region of the world. - Highlights: • We present high-precision Pb isotope data for historical and modern human teeth. • Human teeth reflect human Pb exposure since historical times. • Modern teeth show

  15. The Pb isotopic record of historical to modern human lead exposure

    Energy Technology Data Exchange (ETDEWEB)

    Kamenov, George D., E-mail: kamenov@ufl.edu [Department of Geological Sciences, University of Florida, 241 Williamson Hall, Gainesville, FL 32611 (United States); Gulson, Brian L. [Graduate School of the Environment, Faculty of Science, Macquarie University, Sydney, NSW 2109 (Australia)

    2014-08-15

    Human teeth and bones incorporate trace amounts of lead (Pb) from the local environment during growth and remodeling. Anthropogenic activities have caused changes in the natural Pb isotopic background since historical times and this is reflected in the Pb isotopes of historical European teeth. Lead mining and use increased exponentially during the last century and the isotopic compositions of modern human teeth reflect the modern anthropogenic Pb. USA teeth show the most radiogenic Pb and Australian teeth show the least radiogenic Pb, a result of different Pb ores used in the two regions. During the last century the Australian Pb was exported to Europe, Asia, South America, and Africa, resulting in swamping of the local environmental Pb signal by the imported Pb. As a result, the modern human teeth in Europe show a significant drop to lower isotopic values compared with historical times. Similarly, modern human teeth in other regions of the world show similar Pb isotopic ratios to modern European teeth reflecting the Pb imports. The specific pattern of human Pb exposure allows us to use the Pb isotopic signal recorded in the skeleton as a geo-referencing tool. As historical European teeth show a distinct Pb signal, we can identify early European skeletal remains in the New World and likely elsewhere. In modern forensic investigations we can discriminate to some extent Eastern Europeans from Western and Northern Europeans. Australians can be identified to some extent in any region in the world, although there is some overlap with Western European individuals. Lead isotopes can be used to easily identify foreigners in the USA, as modern USA teeth are distinct from any other region of the world. By analogy, USA individuals can be identified virtually in any other region of the world. - Highlights: • We present high-precision Pb isotope data for historical and modern human teeth. • Human teeth reflect human Pb exposure since historical times. • Modern teeth show

  16. 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

  17. Human health risk assessment of lead from mining activities at semi-arid locations in the context of total lead exposure.

    Science.gov (United States)

    Zheng, Jiajia; Huynh, Trang; Gasparon, Massimo; Ng, Jack; Noller, Barry

    2013-12-01

    Lead from historical mining and mineral processing activities may pose potential human health risks if materials with high concentrations of bioavailable lead minerals are released to the environment. Since the Joint Expert Committee on Food Additives of Food and Agriculture Organization/World Health Organization withdrew the Provisional Tolerable Weekly Intake of lead in 2011, an alternative method was required for lead exposure assessment. This study evaluated the potential lead hazard to young children (0-7 years) from a historical mining location at a semi-arid area using the U.S. EPA Integrated Exposure Uptake Biokinetic (IEUBK) Model, with selected site-specific input data. This study assessed lead exposure via the inhalation pathway for children living in a location affected by lead mining activities and with specific reference to semi-arid conditions and made comparison with the ingestion pathway by using the physiologically based extraction test for gastro-intestinal simulation. Sensitivity analysis for major IEUBK input parameters was conducted. Three groups of input parameters were classified according to the results of predicted blood concentrations. The modelled lead absorption attributed to the inhalation route was lower than 2 % (mean ± SE, 0.9 % ± 0.1 %) of all lead intake routes and was demonstrated as a less significant exposure pathway to children's blood, compared with ingestion. Whilst dermal exposure was negligible, diet and ingestion of soil and dust were the dominant parameters in terms of children's blood lead prediction. The exposure assessment identified the changing role of dietary intake when house lead loadings varied. Recommendations were also made to conduct comprehensive site-specific human health risk assessment in future studies of lead exposure under a semi-arid climate.

  18. TECHNOLOGY VS NATURE: HUMAN ERROR IN DEALING WITH NATURE IN CRICHTON'S JURASSIC PARK

    Directory of Open Access Journals (Sweden)

    Sarah Prasasti

    2000-01-01

    Full Text Available Witnessing the euphoria of the era of biotechnology in the late twentieth century, Crichton exposes the theme of biotechnology in his works. In Jurassic Park, he voices his concern about the impact of the use of biotechnology to preserve nature and its living creatures. He further describes how the purpose of preserving nature and the creatures has turned out to be destructive. This article discusses Crichton's main character, Hammond, who attempts to control nature by genetically recreating the extinct fossil animals. It seems that the attempt ignores his human limitations. Although he is confident that has been equipped with the technology, he forgets to get along with nature. His way of using technology to accomplish his purpose proves not to be in harmony with nature. As a consequence, nature fights back. And he is conquered.

  19. BET 2: Poor evidence on whether teaching cognitive debiasing, or cognitive forcing strategies, lead to a reduction in errors attributable to cognition in emergency medicine students or doctors.

    Science.gov (United States)

    Oliver, Govind; Oliver, Gopal; Body, Rick

    2017-08-01

    A short review was carried out to see if teaching cognitive forcing strategies reduces cognitive error in the practice of emergency medicine. Two relevant papers were found using the described search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. There is currently little evidence that teaching cognitive forcing strategies reduces cognitive error in the practice of emergency medicine. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

  20. De novo centriole formation in human cells is error-prone and does not require SAS-6 self-assembly.

    Science.gov (United States)

    Wang, Won-Jing; Acehan, Devrim; Kao, Chien-Han; Jane, Wann-Neng; Uryu, Kunihiro; Tsou, Meng-Fu Bryan

    2015-11-26

    Vertebrate centrioles normally propagate through duplication, but in the absence of preexisting centrioles, de novo synthesis can occur. Consistently, centriole formation is thought to strictly rely on self-assembly, involving self-oligomerization of the centriolar protein SAS-6. Here, through reconstitution of de novo synthesis in human cells, we surprisingly found that normal looking centrioles capable of duplication and ciliation can arise in the absence of SAS-6 self-oligomerization. Moreover, whereas canonically duplicated centrioles always form correctly, de novo centrioles are prone to structural errors, even in the presence of SAS-6 self-oligomerization. These results indicate that centriole biogenesis does not strictly depend on SAS-6 self-assembly, and may require preexisting centrioles to ensure structural accuracy, fundamentally deviating from the current paradigm.

  1. Functional requirements for the man-vehicle systems research facility. [identifying and correcting human errors during flight simulation

    Science.gov (United States)

    Clement, W. F.; Allen, R. W.; Heffley, R. K.; Jewell, W. F.; Jex, H. R.; Mcruer, D. T.; Schulman, T. M.; Stapleford, R. L.

    1980-01-01

    The NASA Ames Research Center proposed a man-vehicle systems research facility to support flight simulation studies which are needed for identifying and correcting the sources of human error associated with current and future air carrier operations. The organization of research facility is reviewed and functional requirements and related priorities for the facility are recommended based on a review of potentially critical operational scenarios. Requirements are included for the experimenter's simulation control and data acquisition functions, as well as for the visual field, motion, sound, computation, crew station, and intercommunications subsystems. The related issues of functional fidelity and level of simulation are addressed, and specific criteria for quantitative assessment of various aspects of fidelity are offered. Recommendations for facility integration, checkout, and staffing are included.

  2. 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.

  3. 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

  4. Contribution of lead in wine to the total dietary intake of lead in humans with and without a meal

    International Nuclear Information System (INIS)

    Gulson, B.L.; Gray, B.; Mizon, K.J.; Patison, N.

    2000-01-01

    We have undertaken a case-control study using high precision lead isotopes to evaluate the contribution to blood lead when a normal quantity of wine is consumed with a meal and compared this with consumption under fasting conditions. White wine dosed with a 207 Pb tracer was consumed with a meal by a male subject and blood, urine and faeces monitored for up to four months. In addition to the spiked wine, the male subject and a female control subject residing in the same household consumed approximately equal proportions of unspiked red and white wine from the same vintage and vineyard over the four months. On a succeeding occasion, the male subject consumed 207 Pb-spiked wine under fasting conditions. As the 207 Pb/ 204 Pb ratio in blood and urine prior to the experiment was 15.48 compared with a value of 355 in the doped wine, changes in the 207 Pb/ 204 Pb ratio would be easily discernible. Over the four months of the trial, the results confirmed that there is a minimal uptake of lead from vine when consumed with food

  5. Disruption of PH–kinase domain interactions leads to oncogenic activation of AKT in human cancers

    Science.gov (United States)

    Parikh, Chaitali; Janakiraman, Vasantharajan; Wu, Wen-I; Foo, Catherine K.; Kljavin, Noelyn M.; Chaudhuri, Subhra; Stawiski, Eric; Lee, Brian; Lin, Jie; Li, Hong; Lorenzo, Maria N.; Yuan, Wenlin; Guillory, Joseph; Jackson, Marlena; Rondon, Jesus; Franke, Yvonne; Bowman, Krista K.; Sagolla, Meredith; Stinson, Jeremy; Wu, Thomas D.; Wu, Jiansheng; Stokoe, David; Stern, Howard M.; Brandhuber, Barbara J.; Lin, Kui; Skelton, Nicholas J.; Seshagiri, Somasekar

    2012-01-01

    The protein kinase v-akt murine thymoma viral oncogene homolog (AKT), a key regulator of cell survival and proliferation, is frequently hyperactivated in human cancers. Intramolecular pleckstrin homology (PH) domain–kinase domain (KD) interactions are important in maintaining AKT in an inactive state. AKT activation proceeds after a conformational change that dislodges the PH from the KD. To understand these autoinhibitory interactions, we generated mutations at the PH–KD interface and found that most of them lead to constitutive activation of AKT. Such mutations are likely another mechanism by which activation may occur in human cancers and other diseases. In support of this likelihood, we found somatic mutations in AKT1 at the PH–KD interface that have not been previously described in human cancers. Furthermore, we show that the AKT1 somatic mutants are constitutively active, leading to oncogenic signaling. Additionally, our studies show that the AKT1 mutants are not effectively inhibited by allosteric AKT inhibitors, consistent with the requirement for an intact PH–KD interface for allosteric inhibition. These results have important implications for therapeutic intervention in patients with AKT mutations at the PH–KD interface. PMID:23134728

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

    International Nuclear Information System (INIS)

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

    1999-01-01

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

  7. Measurement errors in network load measurement: Effects on lead management and accounting. Messfehler bei der Netzlasterfassung: Einfluss auf Lastregelung und Leistungsverrechnung

    Energy Technology Data Exchange (ETDEWEB)

    Bunten, B. (Teilbereich Lastfuehrung, ABB Netzleittechnik GmbH, Ladenburg (Germany)); Dib, R.N. (Fachhochschule Giessen-Friedberg, Bereich Elektrische Energietechnik, Friedberg (Germany))

    1994-05-16

    In electric power supply systems continuous power measurement in the delivery points is necessary both for the purpose of load-management and for energy and power accounting. Electricity meters with pulse output points are commonly used for both applications today. The authors quantify the resulting errors in peak load measurement and load management as a function of the main influencing factors. (orig.)

  8. Sample size re-assessment leading to a raised sample size does not inflate type I error rate under mild conditions.

    Science.gov (United States)

    Broberg, Per

    2013-07-19

    One major concern with adaptive designs, such as the sample size adjustable designs, has been the fear of inflating the type I error rate. In (Stat Med 23:1023-1038, 2004) it is however proven that when observations follow a normal distribution and the interim result show promise, meaning that the conditional power exceeds 50%, type I error rate is protected. This bound and the distributional assumptions may seem to impose undesirable restrictions on the use of these designs. In (Stat Med 30:3267-3284, 2011) the possibility of going below 50% is explored and a region that permits an increased sample size without inflation is defined in terms of the conditional power at the interim. A criterion which is implicit in (Stat Med 30:3267-3284, 2011) is derived by elementary methods and expressed in terms of the test statistic at the interim to simplify practical use. Mathematical and computational details concerning this criterion are exhibited. Under very general conditions the type I error rate is preserved under sample size adjustable schemes that permit a raise. The main result states that for normally distributed observations raising the sample size when the result looks promising, where the definition of promising depends on the amount of knowledge gathered so far, guarantees the protection of the type I error rate. Also, in the many situations where the test statistic approximately follows a normal law, the deviation from the main result remains negligible. This article provides details regarding the Weibull and binomial distributions and indicates how one may approach these distributions within the current setting. There is thus reason to consider such designs more often, since they offer a means of adjusting an important design feature at little or no cost in terms of error rate.

  9. Acids with an equivalent taste lead to different erosion of human dental enamel.

    Science.gov (United States)

    Beyer, Markus; Reichert, Jörg; Bossert, Jörg; Sigusch, Bernd W; Watts, David C; Jandt, Klaus D

    2011-10-01

    The consumption of acidic soft drinks may lead to demineralization and softening of human dental enamel, known as dental erosion. The aims of this in vitro study were to determine: (i) if different acids with a similar sensorial acidic taste lead to different hardness loss of enamel and (ii) if the fruit acids tartaric, malic, lactic or ascorbic acid lead to less hardness loss of enamel than citric or phosphoric acid when their concentration in solution is based on an equivalent sensorial acidic taste. Enamel samples of non-erupted human third molars were treated with acidic solutions of tartaric (TA), malic (MA), lactic (LA), ascorbic (AA), phosphoric (PA) and citric (CA) acids with a concentration that gave an equivalent sensorial acidic taste. The acidic solutions were characterized by pH value and titratable acidity. Atomic force microscopy (AFM) based nanoindentation was used to study the nano mechanical properties and scanning electron microscopy (SEM) was used to study the morphology of the treated enamel samples and the untreated control areas, respectively. The investigated acids fell into two groups. The nano hardnesses of MA, TA and CA treated enamel samples (group I) were statistically significantly greater (penamel samples (group II). Within each group the nano hardness was not statistically significantly different (p>0.05). The SEM micrographs showed different etch prism morphologies depending on the acid used. In vitro, the acids investigated led to different erosion effects on human dental enamel, despite their equivalent sensorial acidic taste. This has not been reported previously. Copyright © 2011 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

  10. A New Human-Machine Interfaces of Computer-based Procedure System to Reduce the Team Errors in Nuclear Power Plants

    Energy Technology Data Exchange (ETDEWEB)

    Kim, Sa Kil; Sim, Joo Hyun; Lee, Hyun Chul [Korea Atomic Research Institute, Daejeon (Korea, Republic of)

    2016-10-15

    In this study, we identify the emerging types of team errors, especially, in digitalized control room of nuclear power plants such as the APR-1400 main control room of Korea. Most works in nuclear industry are to be performed by a team of more than two persons. Even though the individual errors can be detected and recovered by the qualified others and/or the well trained team, it is rather seldom that the errors by team could be easily detected and properly recovered by the team itself. Note that the team is defined as two or more people who are appropriately interacting with each other, and the team is a dependent aggregate, which accomplishes a valuable goal. Organizational errors sometimes increase the likelihood of operator errors through the active failure pathway and, at the same time, enhance the possibility of adverse outcomes through defensive weaknesses. We incorporate the crew resource management as a representative approach to deal with the team factors of the human errors. We suggest a set of crew resource management training procedures under the unsafe environments where human errors can have devastating effects. We are on the way to develop alternative interfaces against team error in a condition of using a computer-based procedure system in a digitalized main control room. The computer-based procedure system is a representative feature of digitalized control room. In this study, we will propose new interfaces of computer-based procedure system to reduce feasible team errors. We are on the way of effectiveness test to validate whether the new interface can reduce team errors during operating with a computer-based procedure system in a digitalized control room.

  11. A New Human-Machine Interfaces of Computer-based Procedure System to Reduce the Team Errors in Nuclear Power Plants

    International Nuclear Information System (INIS)

    Kim, Sa Kil; Sim, Joo Hyun; Lee, Hyun Chul

    2016-01-01

    In this study, we identify the emerging types of team errors, especially, in digitalized control room of nuclear power plants such as the APR-1400 main control room of Korea. Most works in nuclear industry are to be performed by a team of more than two persons. Even though the individual errors can be detected and recovered by the qualified others and/or the well trained team, it is rather seldom that the errors by team could be easily detected and properly recovered by the team itself. Note that the team is defined as two or more people who are appropriately interacting with each other, and the team is a dependent aggregate, which accomplishes a valuable goal. Organizational errors sometimes increase the likelihood of operator errors through the active failure pathway and, at the same time, enhance the possibility of adverse outcomes through defensive weaknesses. We incorporate the crew resource management as a representative approach to deal with the team factors of the human errors. We suggest a set of crew resource management training procedures under the unsafe environments where human errors can have devastating effects. We are on the way to develop alternative interfaces against team error in a condition of using a computer-based procedure system in a digitalized main control room. The computer-based procedure system is a representative feature of digitalized control room. In this study, we will propose new interfaces of computer-based procedure system to reduce feasible team errors. We are on the way of effectiveness test to validate whether the new interface can reduce team errors during operating with a computer-based procedure system in a digitalized control room

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

    International Nuclear Information System (INIS)

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

    1998-01-01

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

  13. Implications of leading crop production practices on environmental quality and human health.

    Science.gov (United States)

    Udeigwe, Theophilus K; Teboh, Jasper M; Eze, Peter N; Stietiya, M Hashem; Kumar, Vipan; Hendrix, James; Mascagni, Henry J; Ying, Teng; Kandakji, Tarek

    2015-03-15

    Globally, much weight is currently being placed on agriculture to provide food for the growing population as well as feedstock for the bioenergy industry. Unfortunately, the intensification of agricultural operations to satisfy these growing needs has been associated with a number of environmental and human health risks. A review of publications on the subject was conducted and emphasis was placed on articles focusing on agriculture, environment, and public health as well as their interactions. Supporting information was also gathered from publications of various agricultural and environmental agencies. Agricultural practices with potential negative implications on the environment and human health were identified broadly as: (a) utilization of biosolids and animal manures, (b) use of agricultural chemicals, (c) management of post-harvest residue, (d) irrigation, and (e) tillage operations. Soil, water, and air contamination by nutrients, heavy metals, pathogens, and pesticides, as well as air contamination by particulate matters, noxious gases, and pathogens were among the leading environmental impacts. Some of the human-health impacts identified included neurological and reproductive defects, cardiovascular risks, cancers and other diseases (of kidney, liver, lung, and skin), skin allergies, gastroenteritis, and methemoglobinemia. Continual awareness on the impacts of the reviewed agricultural practices on environmental quality and human health and the implementation of experimentally-backed best management practices in agricultural systems remain indispensable. Copyright © 2014 Elsevier Ltd. All rights reserved.

  14. Neurodegeneration caused by expression of human truncated tau leads to progressive neurobehavioural impairment in transgenic rats.

    Science.gov (United States)

    Hrnkova, Miroslava; Zilka, Norbert; Minichova, Zuzana; Koson, Peter; Novak, Michal

    2007-01-26

    Human truncated tau protein is an active constituent of the neurofibrillary degeneration in sporadic Alzheimer's disease. We have shown that modified tau protein, when expressed as a transgene in rats, induced AD characteristic tau cascade consisting of tau hyperphosphorylation, formation of argyrophilic tangles and sarcosyl-insoluble tau complexes. These pathological changes led to the functional impairment characterized by a variety of neurobehavioural symptoms. In the present study we have focused on the behavioural alterations induced by transgenic expression of human truncated tau. Transgenic rats underwent a battery of behavioural tests involving cognitive- and sensorimotor-dependent tasks accompanied with neurological assessment at the age of 4.5, 6 and 9 months. Behavioural examination of these rats showed altered spatial navigation in Morris water maze resulting in less time spent in target quadrant (popen field was not influenced by transgene expression. However beam walking test revealed that transgenic rats developed progressive sensorimotor disturbances related to the age of tested animals. The disturbances were most pronounced at the age of 9 months (p<0.01). Neurological alterations indicating impaired reflex responses were other added features of behavioural phenotype of this novel transgenic rat. These results allow us to suggest that neurodegeneration, caused by the non-mutated human truncated tau derived from sporadic human AD, result in the neuronal dysfunction consequently leading to the progressive neurobehavioural impairment.

  15. Spatial distribution of the trace elements zinc, strontium and lead in human bone tissue.

    Science.gov (United States)

    Pemmer, B; Roschger, A; Wastl, A; Hofstaetter, J G; Wobrauschek, P; Simon, R; Thaler, H W; Roschger, P; Klaushofer, K; Streli, C

    2013-11-01

    Trace elements are chemical elements in minute quantities, which are known to accumulate in the bone. Cortical and trabecular bones consist of bone structural units (BSUs) such as osteons and bone packets of different mineral content and are separated by cement lines. Previous studies investigating trace elements in bone lacked resolution and therefore very little is known about the local concentration of zinc (Zn), strontium (Sr) and lead (Pb) in BSUs of human bone. We used synchrotron radiation induced micro X-ray fluorescence analysis (SR μ-XRF) in combination with quantitative backscattered electron imaging (qBEI) to determine the distribution and accumulation of Zn, Sr, and Pb in human bone tissue. Fourteen human bone samples (10 femoral necks and 4 femoral heads) from individuals with osteoporotic femoral neck fractures as well as from healthy individuals were analyzed. Fluorescence intensity maps were matched with BE images and correlated with calcium (Ca) content. We found that Zn and Pb had significantly increased levels in the cement lines of all samples compared to the surrounding mineralized bone matrix. Pb and Sr levels were found to be correlated with the degree of mineralization. Interestingly, Zn intensities had no correlation with Ca levels. We have shown for the first time that there is a differential accumulation of the trace elements Zn, Pb and Sr in BSUs of human bone indicating different mechanisms of accumulation. © 2013. Published by Elsevier Inc. All rights reserved.

  16. Spatial distribution of the trace elements zinc, strontium and lead in human bone tissue☆

    Science.gov (United States)

    Pemmer, B.; Roschger, A.; Wastl, A.; Hofstaetter, J.G.; Wobrauschek, P.; Simon, R.; Thaler, H.W.; Roschger, P.; Klaushofer, K.; Streli, C.

    2013-01-01

    Trace elements are chemical elements in minute quantities, which are known to accumulate in the bone. Cortical and trabecular bones consist of bone structural units (BSUs) such as osteons and bone packets of different mineral content and are separated by cement lines. Previous studies investigating trace elements in bone lacked resolution and therefore very little is known about the local concentration of zinc (Zn), strontium (Sr) and lead (Pb) in BSUs of human bone. We used synchrotron radiation induced micro X-ray fluorescence analysis (SR μ-XRF) in combination with quantitative backscattered electron imaging (qBEI) to determine the distribution and accumulation of Zn, Sr, and Pb in human bone tissue. Fourteen human bone samples (10 femoral necks and 4 femoral heads) from individuals with osteoporotic femoral neck fractures as well as from healthy individuals were analyzed. Fluorescence intensity maps were matched with BE images and correlated with calcium (Ca) content. We found that Zn and Pb had significantly increased levels in the cement lines of all samples compared to the surrounding mineralized bone matrix. Pb and Sr levels were found to be correlated with the degree of mineralization. Interestingly, Zn intensities had no correlation with Ca levels. We have shown for the first time that there is a differential accumulation of the trace elements Zn, Pb and Sr in BSUs of human bone indicating different mechanisms of accumulation. PMID:23932972

  17. Lead Poisoning

    Science.gov (United States)

    Lead is a metal that occurs naturally in the earth's crust. Lead can be found in all parts of our ... from human activities such as mining and manufacturing. Lead used to be in paint; older houses may ...

  18. Representation of human behaviour in probabilistic safety analysis

    International Nuclear Information System (INIS)

    Whittingham, R.B.

    1991-01-01

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

  19. Socializing the human factors analysis and classification system: incorporating social psychological phenomena into a human factors error classification system.

    Science.gov (United States)

    Paletz, Susannah B F; Bearman, Christopher; Orasanu, Judith; Holbrook, Jon

    2009-08-01

    The presence of social psychological pressures on pilot decision making was assessed using qualitative analyses of critical incident interviews. Social psychological phenomena have long been known to influence attitudes and behavior but have not been highlighted in accident investigation models. Using a critical incident method, 28 pilots who flew in Alaska were interviewed. The participants were asked to describe a situation involving weather when they were pilot in command and found their skills challenged. They were asked to describe the incident in detail but were not explicitly asked to identify social pressures. Pressures were extracted from transcripts in a bottom-up manner and then clustered into themes. Of the 28 pilots, 16 described social psychological pressures on their decision making, specifically, informational social influence, the foot-in-the-door persuasion technique, normalization of deviance, and impression management and self-consistency motives. We believe accident and incident investigations can benefit from explicit inclusion of common social psychological pressures. We recommend specific ways of incorporating these pressures into theHuman Factors Analysis and Classification System.

  20. Computational Breakthrough of Natural Lead Hits from the Genus of Arisaema against Human Respiratory Syncytial Virus.

    Science.gov (United States)

    Kant, Kamal; Lal, Uma Ranjan; Ghosh, Manik

    2018-01-01

    To date, efforts for the prevention and treatment of human respiratory syncytial virus (RSV) infection have been still vain, and there is no safe and effective clinical accepted vaccine. Arisaema genus has claimed for various traditional bioactivities, but scientific assessments are quite limited. This encouraged us to carry out our present study on around 60 phytoconstituents of different Arisaema species as a natural inhibitor against the human RSV. Selected 60 phytochemical entities were evaluated on the docking behavior of human RSV receptor (PDB: 4UCC) using Maestro 9.3 (Schrödinger, LLC, Cambridge, USA). Furthermore, kinetic properties and toxicity nature of top graded ligands were analyzed through QikProp and ProTox tools. Notably, rutin (glide score: -8.49), schaftoside (glide score: -8.18) and apigenin-6,8-di-C-β-D-galactoside (glide score - 7.29) have resulted in hopeful natural lead hits with an ideal range of kinetic descriptors values. ProTox tool (oral rodent toxicity) has resulted in likely toxicity targets of apex-graded tested ligands. Finally, the whole efforts can be explored further as a model to confirm its anti-human RSV potential with wet laboratory experiments. Rutin, schaftoside, and apigenin-6,8-di-C-β-D-galactoside showed promising top hits docking profile against human respiratory syncytial virusMoreover, absorption, distribution, metabolism, excretion properties (QikProp) of top hits resulted within an ideal range of kinetic descriptorsProTox tool highlighted toxicity class ranges, LD 50 values, and possible toxicity targets of apex-graded tested ligands. Abbreviations used: RSV: Respiratory syncytial virus, PRRSV: Porcine respiratory and reproductive syndrome virus, ADME-T: Absorption, distribution, metabolism, excretion, and toxicity.

  1. Detailed analysis of inversions predicted between two human genomes: errors, real polymorphisms, and their origin and population distribution.

    Science.gov (United States)

    Vicente-Salvador, David; Puig, Marta; Gayà-Vidal, Magdalena; Pacheco, Sarai; Giner-Delgado, Carla; Noguera, Isaac; Izquierdo, David; Martínez-Fundichely, Alexander; Ruiz-Herrera, Aurora; Estivill, Xavier; Aguado, Cristina; Lucas-Lledó, José Ignacio; Cáceres, Mario

    2017-02-01

    The growing catalogue of structural variants in humans often overlooks inversions as one of the most difficult types of variation to study, even though they affect phenotypic traits in diverse organisms. Here, we have analysed in detail 90 inversions predicted from the comparison of two independently assembled human genomes: the reference genome (NCBI36/HG18) and HuRef. Surprisingly, we found that two thirds of these predictions (62) represent errors either in assembly comparison or in one of the assemblies, including 27 misassembled regions in HG18. Next, we validated 22 of the remaining 28 potential polymorphic inversions using different PCR techniques and characterized their breakpoints and ancestral state. In addition, we determined experimentally the derived allele frequency in Europeans for 17 inversions (DAF = 0.01-0.80), as well as the distribution in 14 worldwide populations for 12 of them based on the 1000 Genomes Project data. Among the validated inversions, nine have inverted repeats (IRs) at their breakpoints, and two show nucleotide variation patterns consistent with a recurrent origin. Conversely, inversions without IRs have a unique origin and almost all of them show deletions or insertions at the breakpoints in the derived allele mediated by microhomology sequences, which highlights the importance of mechanisms like FoSTeS/MMBIR in the generation of complex rearrangements in the human genome. Finally, we found several inversions located within genes and at least one candidate to be positively selected in Africa. Thus, our study emphasizes the importance of careful analysis and validation of large-scale genomic predictions to extract reliable biological conclusions. © The Author 2016. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  2. Regional and long-term patterns of lead concentrations in fluvial, marine and terrestrial systems and humans in Europe

    Energy Technology Data Exchange (ETDEWEB)

    Hagner, C. [GKSS-Forschungszentrum Geesthacht GmbH (Germany). Inst. fuer Hydrophysik

    2000-07-01

    Lead contamination of abiotic and biotic systems has been studied closely since the early 1970s, when lead was firstly perceived as an environmental problem. Lead emission reduction policies were implemented throughout Europe during that time. Nonetheless, analyses of lead loads in aquatic systems, such as the river Elbe, showed no decline over time in either suspended matter or surface sediments. Regional differences in lead concentrations of fluvial systems were found, due to tidal influence, runoff and local emissions. Lead contamination of sediments from the North Sea was highest in estuaries. Concentrations in sediment cores were quite stable down to the depth of background values, due to bioturbation, flow, waves and meandering channels. Terrestrial soils in Europe were highly polluted in industrial and ore mining areas and large cities. No decline in lead concentrations was evident in foraminifers, bladder wrack or fish. It was found that contamination in sediments, mammals and fish was higher in coastal zones than in the open sea. In contrast to in aquatic organisms, positive impacts of lead reduction regulations were detected in terrestrial plants, which adsorbed or took up lead mainly through atmospheric lead deposition. European lead concentrations in plants decreased coincidently with lead emissions. That trend could also be identified in the blood lead levels of the human population in Europe: since 1979 they have declined in every group of the population. Mainly influenced by age, sex and the living environment, overall, the lead loads of humans had never been high enough to cause health danger. (orig.)

  3. Rigorous Training of Dogs Leads to High Accuracy in Human Scent Matching-To-Sample Performance.

    Directory of Open Access Journals (Sweden)

    Sophie Marchal

    Full Text Available Human scent identification is based on a matching-to-sample task in which trained dogs are required to compare a scent sample collected from an object found at a crime scene to that of a suspect. Based on dogs' greater olfactory ability to detect and process odours, this method has been used in forensic investigations to identify the odour of a suspect at a crime scene. The excellent reliability and reproducibility of the method largely depend on rigor in dog training. The present study describes the various steps of training that lead to high sensitivity scores, with dogs matching samples with 90% efficiency when the complexity of the scents presented during the task in the sample is similar to that presented in the in lineups, and specificity reaching a ceiling, with no false alarms in human scent matching-to-sample tasks. This high level of accuracy ensures reliable results in judicial human scent identification tests. Also, our data should convince law enforcement authorities to use these results as official forensic evidence when dogs are trained appropriately.

  4. Understanding and Confronting Our Mistakes: The Epidemiology of Error in Radiology and Strategies for Error Reduction.

    Science.gov (United States)

    Bruno, Michael A; Walker, Eric A; Abujudeh, Hani H

    2015-10-01

    Arriving at a medical diagnosis is a highly complex process that is extremely error prone. Missed or delayed diagnoses often lead to patient harm and missed opportunities for treatment. Since medical imaging is a major contributor to the overall diagnostic process, it is also a major potential source of diagnostic error. Although some diagnoses may be missed because of the technical or physical limitations of the imaging modality, including image resolution, intrinsic or extrinsic contrast, and signal-to-noise ratio, most missed radiologic diagnoses are attributable to image interpretation errors by radiologists. Radiologic interpretation cannot be mechanized or automated; it is a human enterprise based on complex psychophysiologic and cognitive processes and is itself subject to a wide variety of error types, including perceptual errors (those in which an important abnormality is simply not seen on the images) and cognitive errors (those in which the abnormality is visually detected but the meaning or importance of the finding is not correctly understood or appreciated). The overall prevalence of radiologists' errors in practice does not appear to have changed since it was first estimated in the 1960s. The authors review the epidemiology of errors in diagnostic radiology, including a recently proposed taxonomy of radiologists' errors, as well as research findings, in an attempt to elucidate possible underlying causes of these errors. The authors also propose strategies for error reduction in radiology. On the basis of current understanding, specific suggestions are offered as to how radiologists can improve their performance in practice. © RSNA, 2015.

  5. Implications for wildlife and humans of dietary exposure to lead from fragments of lead rifle bullets in deer shot in the UK

    International Nuclear Information System (INIS)

    Knott, Jeff; Gilbert, Jo; Hoccom, David G.; Green, Rhys E.

    2010-01-01

    Lead poisoning caused by ingested spent lead shotgun pellets has long been known to be a cause of unnecessary mortality in waterfowl and has led to legislation limiting its use in many countries. Recent evidence has shown that the problem extends to terrestrial ecosystems and to fragmented rifle bullets eaten by scavengers as well as shotgun pellets. Dietary exposure of human consumers to lead from spent ammunition in game meat also poses potential risks to human health. To assess the degree of fragmentation of lead bullets used to kill wild deer, twelve deer were shot in the thorax using copper-jacketed lead-cored bullets, as part of planned deer management operations. The thoracic region of the eviscerated carcasses and the abdominal viscera of each deer were X-rayed. An average of 356 metal fragments was visible on radiographs of the carcass and 180 fragments in the viscera. The weight of fragments was estimated by reference to an X-rayed scale of fragments of known weight. The average total weight of metal fragments, likely to be mostly lead, was estimated to be 1.2 g for the carcass and 0.2 g for the viscera. The total estimated weight of fragments in the entire carcass was estimated to be 17% of the weight of the bullet. Most fragments were small in size, with those in the viscera being smaller than those in the carcass. Metal fragments in the viscera were sufficiently small that at least 80% of the metallic bullet-derived lead in the viscera would be expected to be ingested by scavenging birds, such as buzzards and eagles, which feed on them.

  6. Implications for wildlife and humans of dietary exposure to lead from fragments of lead rifle bullets in deer shot in the UK

    Energy Technology Data Exchange (ETDEWEB)

    Knott, Jeff, E-mail: jeff.knott@rspb.org.uk [Royal Society for the Protection of Birds, The Lodge, Sandy, Bedfordshire SG19 2DL (United Kingdom); Gilbert, Jo; Hoccom, David G. [Royal Society for the Protection of Birds, The Lodge, Sandy, Bedfordshire SG19 2DL (United Kingdom); Green, Rhys E. [Royal Society for the Protection of Birds, The Lodge, Sandy, Bedfordshire SG19 2DL (United Kingdom); Conservation Science Group, Department of Zoology, University of Cambridge, Downing Street, Cambridge CB2 3EJ (United Kingdom)

    2010-12-01

    Lead poisoning caused by ingested spent lead shotgun pellets has long been known to be a cause of unnecessary mortality in waterfowl and has led to legislation limiting its use in many countries. Recent evidence has shown that the problem extends to terrestrial ecosystems and to fragmented rifle bullets eaten by scavengers as well as shotgun pellets. Dietary exposure of human consumers to lead from spent ammunition in game meat also poses potential risks to human health. To assess the degree of fragmentation of lead bullets used to kill wild deer, twelve deer were shot in the thorax using copper-jacketed lead-cored bullets, as part of planned deer management operations. The thoracic region of the eviscerated carcasses and the abdominal viscera of each deer were X-rayed. An average of 356 metal fragments was visible on radiographs of the carcass and 180 fragments in the viscera. The weight of fragments was estimated by reference to an X-rayed scale of fragments of known weight. The average total weight of metal fragments, likely to be mostly lead, was estimated to be 1.2 g for the carcass and 0.2 g for the viscera. The total estimated weight of fragments in the entire carcass was estimated to be 17% of the weight of the bullet. Most fragments were small in size, with those in the viscera being smaller than those in the carcass. Metal fragments in the viscera were sufficiently small that at least 80% of the metallic bullet-derived lead in the viscera would be expected to be ingested by scavenging birds, such as buzzards and eagles, which feed on them.

  7. 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

  8. Estimation of lead and zinc in human hair using atomic absorption spectroscopy

    International Nuclear Information System (INIS)

    Kazi, S.; Kazi, T.G.; Kazi, G.H.

    1993-01-01

    Trace elements analysis in hair can be useful in studying the impact of environmental and dietary factors on human in general for lead and zinc content in hair. Samples of people of different age groups, sex with varied living habits of the individual living in different areas of Sind, urban as well as rural areas were of special interest to be studied to find correlation of socioeconomic factors and the presence of these elements in hair samples. The purpose of this study was to determine whether age, sex and physiological status and environmental pollution affect composition of hair. The method of sample preparation and use of atomic absorption techniques providing unequivocal and direct estimation of metals in ppm/ppb range to arrive upon conclusion. (author)

  9. No unified reward prediction error in local field potentials from the human nucleus accumbens: evidence from epilepsy patients.

    Science.gov (United States)

    Stenner, Max-Philipp; Rutledge, Robb B; Zaehle, Tino; Schmitt, Friedhelm C; Kopitzki, Klaus; Kowski, Alexander B; Voges, Jürgen; Heinze, Hans-Jochen; Dolan, Raymond J

    2015-08-01

    Functional magnetic resonance imaging (fMRI), cyclic voltammetry, and single-unit electrophysiology studies suggest that signals measured in the nucleus accumbens (Nacc) during value-based decision making represent reward prediction errors (RPEs), the difference between actual and predicted rewards. Here, we studied the precise temporal and spectral pattern of reward-related signals in the human Nacc. We recorded local field potentials (LFPs) from the Nacc of six epilepsy patients during an economic decision-making task. On each trial, patients decided whether to accept or reject a gamble with equal probabilities of a monetary gain or loss. The behavior of four patients was consistent with choices being guided by value expectations. Expected value signals before outcome onset were observed in three of those patients, at varying latencies and with nonoverlapping spectral patterns. Signals after outcome onset were correlated with RPE regressors in all subjects. However, further analysis revealed that these signals were better explained as outcome valence rather than RPE signals, with gamble gains and losses differing in the power of beta oscillations and in evoked response amplitudes. Taken together, our results do not support the idea that postsynaptic potentials in the Nacc represent a RPE that unifies outcome magnitude and prior value expectation. We discuss the generalizability of our findings to healthy individuals and the relation of our results to measurements of RPE signals obtained from the Nacc with other methods. Copyright © 2015 the American Physiological Society.

  10. Influence of human-machine-interfaces on the error-proneness of operator interaction with technical systems

    International Nuclear Information System (INIS)

    Boussoffara, Badi; Elzer, Peter F.

    1999-01-01

    The paper gives an overview over a research project that has been jointly conducted by four research institutions in Germany since October 1995 with the financial support of the Volkswagen Foundation Germany. The aim of this project is to experimentally investigate the influence of the Human Computer Interface (HCI) on the error-proneness of operators during classification and diagnosis of various process states. Since evaluation of the complete chain 'activation - detection -recognition - diagnosis - action' would have caused some ambiguities with respect to the interpretation of the experimental data only detection and classification of unwanted process states have been evaluated. Depending on the requirements of the various types of experiments the following experimental environments were set up: IPP, IfKog: a simulator of a coal-fired power station (courtesy of ABB); ISTec: a simulator of a nuclear power station (courtesy of GRS); several types of interfaces designed by IPP and IfKog, implemented at IPP; interfaces designed and implemented at ISTec (author) (ml)

  11. Mechanism of error-free DNA synthesis across N1-methyl-deoxyadenosine by human DNA polymerase-ι

    Energy Technology Data Exchange (ETDEWEB)

    Jain, Rinku; Choudhury, Jayati Roy; Buku, Angeliki; Johnson, Robert E.; Prakash, Louise; Prakash, Satya; Aggarwal, Aneel K.

    2017-03-08

    N1-methyl-deoxyadenosine (1-MeA) is formed by methylation of deoxyadenosine at the N1 atom. 1-MeA presents a block to replicative DNA polymerases due to its inability to participate in Watson-Crick (W-C) base pairing. Here we determine how human DNA polymerase-ι (Polι) promotes error-free replication across 1-MeA. Steady state kinetic analyses indicate that Polι is ~100 fold more efficient in incorporating the correct nucleotide T versus the incorrect nucleotide C opposite 1-MeA. To understand the basis of this selectivity, we determined ternary structures of Polι bound to template 1-MeA and incoming dTTP or dCTP. In both structures, template 1-MeA rotates to the syn conformation but pairs differently with dTTP versus dCTP. Thus, whereas dTTP partakes in stable Hoogsteen base pairing with 1-MeA, dCTP fails to gain a “foothold” and is largely disordered. Together, our kinetic and structural studies show how Polι maintains discrimination between correct and incorrect incoming nucleotide opposite 1-MeA in preserving genome integrity.

  12. Science, practice, and human errors in controlling Clostridium botulinum in heat-preserved food in hermetic containers.

    Science.gov (United States)

    Pflug, Irving J

    2010-05-01

    The incidence of botulism in canned food in the last century is reviewed along with the background science; a few conclusions are reached based on analysis of published data. There are two primary aspects to botulism control: the design of an adequate process and the delivery of the adequate process to containers of food. The probability that the designed process will not be adequate to control Clostridium botulinum is very small, probably less than 1.0 x 10(-6), based on containers of food, whereas the failure of the operator of the processing equipment to deliver the specified process to containers of food may be of the order of 1 in 40, to 1 in 100, based on processing units (retort loads). In the commercial food canning industry, failure to deliver the process will probably be of the order of 1.0 x 10(-4) to 1.0 x 10(-6) when U.S. Food and Drug Administration (FDA) regulations are followed. Botulism incidents have occurred in food canning plants that have not followed the FDA regulations. It is possible but very rare to have botulism result from postprocessing contamination. It may thus be concluded that botulism incidents in canned food are primarily the result of human failure in the delivery of the designed or specified process to containers of food that, in turn, result in the survival, outgrowth, and toxin production of C. botulinum spores. Therefore, efforts in C. botulinum control should be concentrated on reducing human errors in the delivery of the specified process to containers of food.

  13. Team errors: definition and taxonomy

    International Nuclear Information System (INIS)

    Sasou, Kunihide; Reason, James

    1999-01-01

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

  14. Information Management System Development for the Investigation, Reporting, and Analysis of Human Error in Naval Aviation Maintenance

    National Research Council Canada - National Science Library

    Nelson, Douglas

    2001-01-01

    The purpose of this research is to evaluate and refine a safety information management system that will facilitate data collection, organization, query, analysis and reporting of maintenance errors...

  15. Errors in Neonatology

    OpenAIRE

    Antonio Boldrini; Rosa T. Scaramuzzo; Armando Cuttano

    2013-01-01

    Introduction: Danger and errors are inherent in human activities. In medical practice errors can lean to adverse events for patients. Mass media echo the whole scenario. Methods: We reviewed recent published papers in PubMed database to focus on the evidence and management of errors in medical practice in general and in Neonatology in particular. We compared the results of the literature with our specific experience in Nina Simulation Centre (Pisa, Italy). Results: In Neonatology the main err...

  16. Error Patterns

    NARCIS (Netherlands)

    Hoede, C.; Li, Z.

    2001-01-01

    In coding theory the problem of decoding focuses on error vectors. In the simplest situation code words are $(0,1)$-vectors, as are the received messages and the error vectors. Comparison of a received word with the code words yields a set of error vectors. In deciding on the original code word,

  17. Bioaccessibility and human health risk assessment of lead in soil from Daye City

    Science.gov (United States)

    Li, Q.; Li, F.; Xiao, M. S.; Cai, Y.; Xiong, L.; Huang, J. B.; Fu, J. T.

    2018-01-01

    Lead (Pb) in soil from 4 sampling sites of Daye City was studied. Bioaccessibilities of Pb in soil were determined by the method of simplified bioaccessible extraction test (SBET). Since traditional health risk assessment was built on the basis of metal total content, the risk may be overestimated. Modified human health risk assessment model considering bioaccessibility was built in this study. Health risk of adults and children exposure to Pb based on total contents and bioaccessible contents were evaluated. The results showed that bioaccessible content of Pb in soil was much lower than its total content, and the average bioaccessible factor (BF) was only 25.37%. The hazard indexes (HIs) for adults and children calculated by two methods were all lower than 1. It indicated that there were no no-carcinogenic risks of Pb for human in Daye. By comparing with the results, the average bioaccessible HIs for adults and children were lower than the total one, which was due to the lower hazard quotient (HQ). Proportions of non-carcinogenic risk exposure to Pb via different pathways have also changed. Particularly, the most main risk exposure pathway for adults turned from the oral ingestion to the inhalation.

  18. Comparison of five in vitro digestion models to in vivo experimental results: Lead bioaccessibility in the human gastrointestinal tract

    NARCIS (Netherlands)

    Wiele, T.R. van de; Oomen, A.G.; Wragg, J.; Cave, M.; Minekus, M.; Hack, A.; Cornelis, C.; Rompelberg, C.J.M.; Zwart, L.L. de; Klinck, B.; Wijnen, J. van; Verstraete, W.; Sips, A.J.A.M.

    2007-01-01

    This paper presents a multi-laboratory comparison study of in vitro models assessing bioaccessibility of soil-bound lead in the human gastrointestinal tract under simulated fasted and fed conditions. Oral bioavailability data from a previous human in vivo study on the same soil served as a reference

  19. Potential Hazard to Human Health from Exposure to Fragments of Lead Bullets and Shot in the Tissues of Game Animals

    Science.gov (United States)

    Pain, Deborah J.; Cromie, Ruth L.; Newth, Julia; Brown, Martin J.; Crutcher, Eric; Hardman, Pippa; Hurst, Louise; Mateo, Rafael; Meharg, Andrew A.; Moran, Annette C.; Raab, Andrea; Taggart, Mark A.; Green, Rhys E.

    2010-01-01

    Background Lead is highly toxic to animals. Humans eating game killed using lead ammunition generally avoid swallowing shot or bullets and dietary lead exposure from this source has been considered low. Recent evidence illustrates that lead bullets fragment on impact, leaving small lead particles widely distributed in game tissues. Our paper asks whether lead gunshot pellets also fragment upon impact, and whether lead derived from spent gunshot and bullets in the tissues of game animals could pose a threat to human health. Methodology/Principal Findings Wild-shot gamebirds (6 species) obtained in the UK were X-rayed to determine the number of shot and shot fragments present, and cooked using typical methods. Shot were then removed to simulate realistic practice before consumption, and lead concentrations determined. Data from the Veterinary Medicines Directorate Statutory Surveillance Programme documenting lead levels in raw tissues of wild gamebirds and deer, without shot being removed, are also presented. Gamebirds containing ≥5 shot had high tissue lead concentrations, but some with fewer or no shot also had high lead concentrations, confirming X-ray results indicating that small lead fragments remain in the flesh of birds even when the shot exits the body. A high proportion of samples from both surveys had lead concentrations exceeding the European Union Maximum Level of 100 ppb w.w. (0.1 mg kg−1 w.w.) for meat from bovine animals, sheep, pigs and poultry (no level is set for game meat), some by several orders of magnitude. High, but feasible, levels of consumption of some species could result in the current FAO/WHO Provisional Weekly Tolerable Intake of lead being exceeded. Conclusions/Significance The potential health hazard from lead ingested in the meat of game animals may be larger than previous risk assessments indicated, especially for vulnerable groups, such as children, and those consuming large amounts of game. PMID:20436670

  20. Potential hazard to human health from exposure to fragments of lead bullets and shot in the tissues of game animals.

    Directory of Open Access Journals (Sweden)

    Deborah J Pain

    Full Text Available BACKGROUND: Lead is highly toxic to animals. Humans eating game killed using lead ammunition generally avoid swallowing shot or bullets and dietary lead exposure from this source has been considered low. Recent evidence illustrates that lead bullets fragment on impact, leaving small lead particles widely distributed in game tissues. Our paper asks whether lead gunshot pellets also fragment upon impact, and whether lead derived from spent gunshot and bullets in the tissues of game animals could pose a threat to human health. METHODOLOGY/PRINCIPAL FINDINGS: Wild-shot gamebirds (6 species obtained in the UK were X-rayed to determine the number of shot and shot fragments present, and cooked using typical methods. Shot were then removed to simulate realistic practice before consumption, and lead concentrations determined. Data from the Veterinary Medicines Directorate Statutory Surveillance Programme documenting lead levels in raw tissues of wild gamebirds and deer, without shot being removed, are also presented. Gamebirds containing > or =5 shot had high tissue lead concentrations, but some with fewer or no shot also had high lead concentrations, confirming X-ray results indicating that small lead fragments remain in the flesh of birds even when the shot exits the body. A high proportion of samples from both surveys had lead concentrations exceeding the European Union Maximum Level of 100 ppb w.w. (0.1 mg kg(-1 w.w. for meat from bovine animals, sheep, pigs and poultry (no level is set for game meat, some by several orders of magnitude. High, but feasible, levels of consumption of some species could result in the current FAO/WHO Provisional Weekly Tolerable Intake of lead being exceeded. CONCLUSIONS/SIGNIFICANCE: The potential health hazard from lead ingested in the meat of game animals may be larger than previous risk assessments indicated, especially for vulnerable groups, such as children, and those consuming large amounts of game.

  1. Potential hazard to human health from exposure to fragments of lead bullets and shot in the tissues of game animals.

    Science.gov (United States)

    Pain, Deborah J; Cromie, Ruth L; Newth, Julia; Brown, Martin J; Crutcher, Eric; Hardman, Pippa; Hurst, Louise; Mateo, Rafael; Meharg, Andrew A; Moran, Annette C; Raab, Andrea; Taggart, Mark A; Green, Rhys E

    2010-04-26

    Lead is highly toxic to animals. Humans eating game killed using lead ammunition generally avoid swallowing shot or bullets and dietary lead exposure from this source has been considered low. Recent evidence illustrates that lead bullets fragment on impact, leaving small lead particles widely distributed in game tissues. Our paper asks whether lead gunshot pellets also fragment upon impact, and whether lead derived from spent gunshot and bullets in the tissues of game animals could pose a threat to human health. Wild-shot gamebirds (6 species) obtained in the UK were X-rayed to determine the number of shot and shot fragments present, and cooked using typical methods. Shot were then removed to simulate realistic practice before consumption, and lead concentrations determined. Data from the Veterinary Medicines Directorate Statutory Surveillance Programme documenting lead levels in raw tissues of wild gamebirds and deer, without shot being removed, are also presented. Gamebirds containing > or =5 shot had high tissue lead concentrations, but some with fewer or no shot also had high lead concentrations, confirming X-ray results indicating that small lead fragments remain in the flesh of birds even when the shot exits the body. A high proportion of samples from both surveys had lead concentrations exceeding the European Union Maximum Level of 100 ppb w.w. (0.1 mg kg(-1) w.w.) for meat from bovine animals, sheep, pigs and poultry (no level is set for game meat), some by several orders of magnitude. High, but feasible, levels of consumption of some species could result in the current FAO/WHO Provisional Weekly Tolerable Intake of lead being exceeded. The potential health hazard from lead ingested in the meat of game animals may be larger than previous risk assessments indicated, especially for vulnerable groups, such as children, and those consuming large amounts of game.

  2. Review of pollutant lead decline in urban air and human blood: A case study from northwestern Europe

    Science.gov (United States)

    Petit, Daniel; Véron, Alain; Flament, Pascal; Deboudt, Karine; Poirier, André

    2015-09-01

    A review of the transient decline of pollutant lead in the air (PbA) and the blood (PbB) has been conducted in order to assess the relationship between these environmental reservoirs. We have demonstrated that PbA decreased 20 to 100 times more than PbB for the past 30 years, suggesting another significant intake besides airborne lead to explain lead accumulated in humans. This trend has also been observed in two blood surveys we have completed in 1976-1978 and 2008-2009 in northern France and Belgium. Nowadays, the mean PbB (1.5-3.5 μg/dL) remains at least 100 times higher than the estimated non-contaminated PbB. Lead isotope imprints in blood could help decipher specific contamination cases, and were coherent with the decline of PbA, but could not help discriminate the source of blood lead owing to the lack of source imprints, especially from dietary intakes. Correlations between recent PbB, isotopic imprints and the age of the subjects suggested that lead released from bones has become a significant source of lead in blood. The significant cause for human exposure to lead may have shifted from direct pollutant lead input accumulated in exogenous reservoirs (air and diet) to endogenous lead release from bone tissues consequential to metabolic calcium homeostasis and bone turnover.

  3. Design for Error Tolerance

    DEFF Research Database (Denmark)

    Rasmussen, Jens

    1983-01-01

    An important aspect of the optimal design of computer-based operator support systems is the sensitivity of such systems to operator errors. The author discusses how a system might allow for human variability with the use of reversibility and observability.......An important aspect of the optimal design of computer-based operator support systems is the sensitivity of such systems to operator errors. The author discusses how a system might allow for human variability with the use of reversibility and observability....

  4. Computational analysis of histidine mutations on the structural stability of human tyrosinases leading to albinism insurgence.

    Science.gov (United States)

    Hassan, Mubashir; Abbas, Qamar; Raza, Hussain; Moustafa, Ahmed A; Seo, Sung-Yum

    2017-07-25

    Misfolding and structural alteration in proteins lead to serious malfunctions and cause various diseases in humans. Mutations at the active binding site in tyrosinase impair structural stability and cause lethal albinism by abolishing copper binding. To evaluate the histidine mutational effect, all mutated structures were built using homology modelling. The protein sequence was retrieved from the UniProt database, and 3D models of original and mutated human tyrosinase sequences were predicted by changing the residual positions within the target sequence separately. Structural and mutational analyses were performed to interpret the significance of mutated residues (N 180 , R 202 , Q 202 , R 211 , Y 363 , R 367 , Y 367 and D 390 ) at the active binding site of tyrosinases. CSpritz analysis depicted that 23.25% residues actively participate in the instability of tyrosinase. The accuracy of predicted models was confirmed through online servers ProSA-web, ERRAT score and VERIFY 3D values. The theoretical pI and GRAVY generated results also showed the accuracy of the predicted models. The CCA negative correlation results depicted that the replacement of mutated residues at His within the active binding site disturbs the structural stability of tyrosinases. The predicted CCA scores of Tyr 367 (-0.079) and Q/R 202 (0.032) revealed that both mutations have more potential to disturb the structural stability. MD simulation analyses of all predicted models justified that Gln 202 , Arg 202 , Tyr 367 and D 390 replacement made the protein structures more susceptible to destabilization. Mutational results showed that the replacement of His with Q/R 202 and Y/R 363 has a lethal effect and may cause melanin associated diseases such as OCA1. Taken together, our computational analysis depicts that the mutated residues such as Q/R 202 and Y/R 363 actively participate in instability and misfolding of tyrosinases, which may govern OCA1 through disturbing the melanin biosynthetic pathway.

  5. Lead (Pb) in sheep exposed to mining pollution: implications for animal and human health.

    Science.gov (United States)

    Pareja-Carrera, Jennifer; Mateo, Rafael; Rodríguez-Estival, Jaime

    2014-10-01

    Livestock from the ancient mining area of Sierra Madrona and Alcudia Valley (Spain) is exposed to elevated levels of lead (Pb), as previous studies based on blood monitoring have revealed. Here we have studied blood, liver and muscle Pb levels in sheep in order to know if Pb exposure could represent a risk for human consumers of the meat and offal of these animals. A cross-sectional study was conducted with ≥4 years old (adults) ewes from the mining area (n=46) and a control area (n=21). Blood samples were taken before the sacrifice at the slaughterhouse, and liver and muscle samples were taken thereafter. At the same time, 2-3 year old rams (subadults, n=17) were blood sampled in the mining area. Blood, liver and muscle Pb levels were higher in the mining than in the control area. Blood Pb concentration in the mining area (n= 44, mean: 6.7μg/dl in ewes and 10.9μg/dl in rams) was above background levels (>6μg/dl) in 73.3 percent of animals. Liver Pb concentration in 68 percent of sheep from the mining area (n=32, mean: 6.16μg/g dry weight, d.w.) exceeded the minimum level associated with toxic exposure (5µg/g d.w.) and 87.5 percent of liver samples were above European Union Maximum Residue Levels (MRL) established for offal destined for human consumption (0.5µg/g w.w.~1.4µg/g d.w.). On the contrary, none of the muscle samples in ewes exceeded the EU MRL (0.1µg/g w.w.~0.34µg/g d.w.) established for meat, which may be related to the decline of blood Pb levels with age observed in the present study. These results suggest a potential health effect for sheep exposed to Pb pollution in this area and implications for food safety, but further research with lamb meat may be necessary to refine the risk assessment for human consumers. Copyright © 2014 Elsevier Inc. All rights reserved.

  6. Interaction of differentiated human adipocytes with macrophages leads to trogocytosis and selective IL-6 secretion.

    Science.gov (United States)

    Sárvári, A K; Doan-Xuan, Q-M; Bacsó, Z; Csomós, I; Balajthy, Z; Fésüs, L

    2015-01-22

    Obesity leads to adipose tissue inflammation that is characterized by increased release of proinflammatory molecules and the recruitment of activated immune cells. Although macrophages are present in the highest number among the immune cells in obese adipose tissue, not much is known about their direct interaction with adipocytes. We have introduced an ex vivo experimental system to characterize the cellular interactions and the profile of secreted cytokines in cocultures of macrophages and human adipocytes differentiated from either mesenchymal stem cells or a preadipocyte cell line. As observed by time-lapse microscopy, flow, and laser-scanning cytometry, macrophages phagocytosed bites of adipocytes (trogocytosis), which led to their de novo, phagocytosis and NF-κB-dependent synthesis, then release of interleukin (IL)-6 and monocyte chemoattractant protein (MCP)-1. IL-6 secretion was not accompanied by secretion of other proinflammatory cytokines, such as tumor necrosis factor (TNF)-α and IL-8, except MCP-1. LPS-induced release of TNF-α, IL-8 and MCP-1 was decreased in the presence of the differentiated adipocytes but the IL-6 level did not subside suggesting that phagocytosis-dependent IL-6 secretion may have significant regulatory function in the inflamed adipose tissue.

  7. Mechanism of inhibition of human secretory phospholipase A2 by flavonoids: rationale for lead design

    Science.gov (United States)

    Lättig, Jens; Böhl, Markus; Fischer, Petra; Tischer, Sandra; Tietböhl, Claudia; Menschikowski, Mario; Gutzeit, Herwig O.; Metz, Peter; Pisabarro, M. Teresa

    2007-08-01

    The human secretory phospholipase A2 group IIA (PLA2-IIA) is a lipolytic enzyme. Its inhibition leads to a decrease in eicosanoids levels and, thereby, to reduced inflammation. Therefore, PLA2-IIA is of high pharmacological interest in treatment of chronic diseases such as asthma and rheumatoid arthritis. Quercetin and naringenin, amongst other flavonoids, are known for their anti-inflammatory activity by modulation of enzymes of the arachidonic acid cascade. However, the mechanism by which flavonoids inhibit Phospholipase A2 (PLA2) remained unclear so far. Flavonoids are widely produced in plant tissues and, thereby, suitable targets for pharmaceutical extractions and chemical syntheses. Our work focuses on understanding the binding modes of flavonoids to PLA2, their inhibition mechanism and the rationale to modify them to obtain potent and specific inhibitors. Our computational and experimental studies focused on a set of 24 compounds including natural flavonoids and naringenin-based derivatives. Experimental results on PLA2-inhibition showed good inhibitory activity for quercetin, kaempferol, and galangin, but relatively poor for naringenin. Several naringenin derivatives were synthesized and tested for affinity and inhibitory activity improvement. 6-(1,1-dimethylallyl)naringenin revealed comparable PLA2 inhibition to quercetin-like compounds. We characterized the binding mode of these compounds and the determinants for their affinity, selectivity, and inhibitory potency. Based on our results, we suggest C(6) as the most promising position of the flavonoid scaffold to introduce chemical modifications to improve affinity, selectivity, and inhibition of PLA2-IIA by flavonoids.

  8. Silver and lead in high-altitude lake sediments: Proxies for climate changes and human activities

    International Nuclear Information System (INIS)

    Garçon, Marion; Chauvel, Catherine; Chapron, Emmanuel; Faïn, Xavier; Lin, Mingfang; Campillo, Sylvain; Bureau, Sarah; Desmet, Marc; Bailly-Maître, Marie-Christine; Charlet, Laurent

    2012-01-01

    High-altitude lake sediments are often used as archives for environmental changes and their chemical and isotopic compositions provide significant constraints on natural and anthropogenic long-term changes that have occurred in their catchment area. Here, trace-element concentrations and Pb isotopes are presented for two sedimentary cores from Lake Blanc Huez in the French Alps, to trace the impact of climate changes and human activities over the Holocene. Lead and Ag contents are very high and clearly dominated by input from a Pb–Ag vein located a few meters from the lakeshore, a vein that also buffers the Pb isotopes. Mining of this vein in medieval times is recorded in the corresponding lake sediments with high Ag content coupled with high Pb/U ratio. These chemical characteristics can be used to constrain the major Holocene climate changes. Significant advances of glaciers next to the lake produced sediments with Ag and Pb concentration peaks and high Pb/U ratios due to accelerated erosion of the Pb–Ag vein, similar to the effects of the medieval mining. In contrast, reduced glacier activity led to the formation of organic-rich sediments with high U and As contents and low Pb/U ratios. More generally, the observed combination of chemical changes could be used elsewhere to decipher environmental changes over long periods of time.

  9. 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

  10. EMG Versus Torque Control of Human-Machine Systems: Equalizing Control Signal Variability Does not Equalize Error or Uncertainty.

    Science.gov (United States)

    Johnson, Reva E; Kording, Konrad P; Hargrove, Levi J; Sensinger, Jonathon W

    2017-06-01

    In this paper we asked the question: if we artificially raise the variability of torque control signals to match that of EMG, do subjects make similar errors and have similar uncertainty about their movements? We answered this question using two experiments in which subjects used three different control signals: torque, torque+noise, and EMG. First, we measured error on a simple target-hitting task in which subjects rec