Indian Journal of Science and Technology

Open Access Open Access  Restricted Access Subscription Access

Structure of Human Errors in Tasks of Operators Working in the Control Room of an Oil Refinery Unit


Affiliations
1 Department of Occupational Health Engineering, School of public Health, International branch of Shahid Beheshti University of Medical Sciences and Health Services
2 Occupational Health Engineering Department, Faculty of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Islamic Republic of
3 Department of Occupational Health, Faculty Member, Qazvin University of medical science, Qazvin, Iran, Islamic Republic of
4 Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Islamic Republic of
5 Sharif university of technology, Strategic management PHD
6 Department of Environmental Science, Science and Research Branch, Islamic Azad University, Tehran, Iran, Islamic Republic of
 

In the present research, human errors existed in tasks of operators working in two control rooms (Northern and Southern control rooms) in the Tehran oil refinery are identified and evaluated. Then, corrective strategies and actions are advised to decrease errors. At first, using hierarchical task analysis (HTA) method, four positions including shift controller, head operators, control room's operators, and outside operators are analyzed. Afterwards, human errors in the considered positions are identified and assessed using technique for retrospective and predictive analysis of cognitive errors (TRACEr). Results present 670 internal errors and 738 external errors in the Northern sector while 661 internal errors and 744 external errors in the Southern sector. In two sectors, this number of errors was identified for 27 major tasks and 108 minor tasks. Action errors are the most repeated errors among the internal errors while violation errors are the least. In addition, most of external errors are related to communication errors while the least errors are related to time and sequence errors. According to results of applying psychological error mechanism (PEM) in the considered positions, people's distraction is the main factor causing errors. Performance shaping factors (PFS) identifies lack of training as the major factor for errors. Using TRACEr, all external and internal errors, psychological error mechanism, and primary factors of errors in the control room can be detected.

Keywords

Operator, Human Error, TRACEr, HTA, Tehran Oil Refinery
User

  • Ghalenovi M (2006) Safety analysis of control room operators human error with HEART technique in a petrochemical plant, A dissertation thesis for the fulfillment of the M.Sc. degree in occupational health engineering, Tarbiat Modarres Univ., Tehran,Iran. [in Persian]

  • Ghasemi M (2009) Ergonomics study (Identification, Prediction & Control) of Human errors in a control room of petrochemical plants using SHERPA, A dissertation thesis for the fulfillment of the M.Sc. degree in Occupational health engineering. Tehran Univ. Medical Sci., Tehran, Iran. [in Persian].

  • ICSO (2004a) Investigation of marine oil and gas' events within recent thirty years. A quarterly J. Health, Safety and environ. Manage. Sys. Iran Continental Shelf Oil Company, summer 2004, No. 8.

  • ICSO (2004b) The accidents of Iran Continental Shelf Oil Company in last 30 years. A quarterly J. Health, Safety and environ. Manage. Sys. Iran Continental ShelfOil Company, summer 2004, No. 6.

  • Jahangiri M (2005) Human error identification and analysis in Isomax unit of Tehran oil refinery, Using PHEA. A dissertation thesis for the fulfillment of theM.Sc. degree in Occupational Health Engineering.Tehran Univ. Medi. Sci. 2005, Tehran, Iran. [in Persian]

  • Le Bot P (2004) Human reliability data, human error and accident models—illustration through the Three Mile Island accident analysis. Reliability Engg. & Sys. Safety.83(2), 153–167.

  • Reason J (1990) Human error. Cambridge Univ. press, NY.

  • RSSB (2005) Rail-specific human reliability assessment technique for driving tasks (T270). Rail Safety & Standards Board. February.

  • Shorrock ST (2005) Errors of memory in air traffic control. Safety Sci. 43(8), 571–588.

  • Shorrock ST (2007) Errors of perception in air traffic control. Safety Sci. 45(8), 890–904.

  • Shorrock ST (2002) The two-fold path to human error analysis: TRACEr lite retrospection and prediction. Safety Sys. (Newsletter of the Safety-Critical SystemsClub), September 2002. 11(3).

  • Shorrock ST and Kirwan B (2002) Development andapplication of a human error identification tool for air traffic control. Appl. Ergonomics. 33(4), 319–336.

  • Stanton N and Salmon P (2004) Human factors design & evaluation methods review. Defense Technol. Center, February, 2004.

  • Zarea A (1996) Human errors of operators in cement furnace using HRMS. A dissertation thesis for the fulfillment of the MSc degree in Occupational Health Engineering. Tehran Univ. Medical Sci., Tehran, Iran. [- in Persian].

  • Zarei M (2009) The assessment of fire and explosion risk at Isomax unit of Tehran Oil Refinery using DOW F&E index and the effectiveness of control measures, Thesis submitted for master's degree. Shahid Beheshti Univ. Medical Sci. & health service-Faculty of Health. [inPersian].

  • Zhang J, Patel VL, Johnson TR and Shortliffe EH (2004) A cognitive taxonomy of medical errors. J. Biomed. Informatics. 37(3), 193-204.


Abstract Views: 458

PDF Views: 142




  • Structure of Human Errors in Tasks of Operators Working in the Control Room of an Oil Refinery Unit

Abstract Views: 458  |  PDF Views: 142

Authors

Niloufar Shah Gholi-Nejad
Department of Occupational Health Engineering, School of public Health, International branch of Shahid Beheshti University of Medical Sciences and Health Services
Mohammad Javad Jafari
Occupational Health Engineering Department, Faculty of Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Islamic Republic of
Mehran Ghalehnoi
Department of Occupational Health, Faculty Member, Qazvin University of medical science, Qazvin, Iran, Islamic Republic of
Yadollah Mehrabi
Department of Epidemiology, School of Public Health, Shahid Beheshti University of Medical Sciences, Tehran, Iran, Islamic Republic of
Mohsen Ghadiri
Sharif university of technology, Strategic management PHD
Mahmood Nikbakht
Department of Environmental Science, Science and Research Branch, Islamic Azad University, Tehran, Iran, Islamic Republic of

Abstract


In the present research, human errors existed in tasks of operators working in two control rooms (Northern and Southern control rooms) in the Tehran oil refinery are identified and evaluated. Then, corrective strategies and actions are advised to decrease errors. At first, using hierarchical task analysis (HTA) method, four positions including shift controller, head operators, control room's operators, and outside operators are analyzed. Afterwards, human errors in the considered positions are identified and assessed using technique for retrospective and predictive analysis of cognitive errors (TRACEr). Results present 670 internal errors and 738 external errors in the Northern sector while 661 internal errors and 744 external errors in the Southern sector. In two sectors, this number of errors was identified for 27 major tasks and 108 minor tasks. Action errors are the most repeated errors among the internal errors while violation errors are the least. In addition, most of external errors are related to communication errors while the least errors are related to time and sequence errors. According to results of applying psychological error mechanism (PEM) in the considered positions, people's distraction is the main factor causing errors. Performance shaping factors (PFS) identifies lack of training as the major factor for errors. Using TRACEr, all external and internal errors, psychological error mechanism, and primary factors of errors in the control room can be detected.

Keywords


Operator, Human Error, TRACEr, HTA, Tehran Oil Refinery

References





DOI: https://doi.org/10.17485/ijst%2F2012%2Fv5i2%2F30343