上游设施事故调查中的人为错误研究

IF 1 4区 工程技术 Q4 ENGINEERING, CHEMICAL Process Safety Progress Pub Date : 2024-02-04 DOI:10.1002/prs.12584
Abdul Hafiz Abd Halim, Tinia Idaty Mohd Ghazi, Faizah Mohd Yassin, Mohd Zahirasri Mohd Tohir
{"title":"上游设施事故调查中的人为错误研究","authors":"Abdul Hafiz Abd Halim, Tinia Idaty Mohd Ghazi, Faizah Mohd Yassin, Mohd Zahirasri Mohd Tohir","doi":"10.1002/prs.12584","DOIUrl":null,"url":null,"abstract":"Human failures are a major cause of breakdowns in upstream facilities because of challenging working conditions. A study of human errors from an incident investigation in upstream facilities was carried out to understand the topography of human errors. A Tripod Beta diagram was developed from 107 incidents gathered during 2017–2020, and the human error taxonomy was used to identify the human errors caused by individuals and contributory human factors responsible for the incidents. A mistake is the most common human failing in a major incident, contributing to 59%, followed by a violation and a skill-based error with scores of 36% and 5%, respectively. Knowledge-based mistakes were prevalent in 48% of the analyzed reports, indicating a significant gap in any decision involving problem-solving and diagnosis. Situational and routine violations with 14% and 10% scoring, respectively, show the complexity of the offshore work environment, which prompts workers to violate and believe that jobs cannot be completed without violations. Disciplinary action, providing a safer workplace, and enhancing the safety culture were proposed to combat workplace violations. Meanwhile, an up-skilling of the workforce with adequate information and instruction will mitigate human errors leading to a mistake. Lastly, revisiting human factor engineering is required to prevent slip and lapse errors.","PeriodicalId":20680,"journal":{"name":"Process Safety Progress","volume":"22 1","pages":""},"PeriodicalIF":1.0000,"publicationDate":"2024-02-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Study of human error from incident investigation in upstream facilities\",\"authors\":\"Abdul Hafiz Abd Halim, Tinia Idaty Mohd Ghazi, Faizah Mohd Yassin, Mohd Zahirasri Mohd Tohir\",\"doi\":\"10.1002/prs.12584\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"Human failures are a major cause of breakdowns in upstream facilities because of challenging working conditions. A study of human errors from an incident investigation in upstream facilities was carried out to understand the topography of human errors. A Tripod Beta diagram was developed from 107 incidents gathered during 2017–2020, and the human error taxonomy was used to identify the human errors caused by individuals and contributory human factors responsible for the incidents. A mistake is the most common human failing in a major incident, contributing to 59%, followed by a violation and a skill-based error with scores of 36% and 5%, respectively. Knowledge-based mistakes were prevalent in 48% of the analyzed reports, indicating a significant gap in any decision involving problem-solving and diagnosis. Situational and routine violations with 14% and 10% scoring, respectively, show the complexity of the offshore work environment, which prompts workers to violate and believe that jobs cannot be completed without violations. Disciplinary action, providing a safer workplace, and enhancing the safety culture were proposed to combat workplace violations. Meanwhile, an up-skilling of the workforce with adequate information and instruction will mitigate human errors leading to a mistake. Lastly, revisiting human factor engineering is required to prevent slip and lapse errors.\",\"PeriodicalId\":20680,\"journal\":{\"name\":\"Process Safety Progress\",\"volume\":\"22 1\",\"pages\":\"\"},\"PeriodicalIF\":1.0000,\"publicationDate\":\"2024-02-04\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Process Safety Progress\",\"FirstCategoryId\":\"5\",\"ListUrlMain\":\"https://doi.org/10.1002/prs.12584\",\"RegionNum\":4,\"RegionCategory\":\"工程技术\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q4\",\"JCRName\":\"ENGINEERING, CHEMICAL\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Process Safety Progress","FirstCategoryId":"5","ListUrlMain":"https://doi.org/10.1002/prs.12584","RegionNum":4,"RegionCategory":"工程技术","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q4","JCRName":"ENGINEERING, CHEMICAL","Score":null,"Total":0}
引用次数: 0

摘要

由于工作条件具有挑战性,人为失误是上游设施发生故障的主要原因。为了了解人为失误的地形,我们对上游设施事故调查中的人为失误进行了研究。根据 2017-2020 年期间收集的 107 起事故绘制了三足鼎立 Beta 图,并使用人为失误分类法确定了由个人造成的人为失误以及造成事故的人为因素。在重大事件中,失误是最常见的人为失误,占 59%,其次是违反规定和基于技能的失误,分别占 36%和 5%。在所分析的报告中,48%的报告普遍存在知识性错误,这表明在任何涉及解决问题和诊断的决策中都存在重大差距。情境性违规和例行性违规分别占 14%和 10%,这表明离岸工作环境的复杂性,这促使工人违规,并认为没有违规就无法完成工作。建议通过纪律处分、提供更安全的工作场所和加强安全文化来打击工作场所的违章行为。同时,通过提供充足的信息和指导来提高工人的技能,可以减少导致失误的人为错误。最后,需要重新审视人为因素工程,以防止滑倒和失误。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
查看原文
分享 分享
微信好友 朋友圈 QQ好友 复制链接
本刊更多论文
Study of human error from incident investigation in upstream facilities
Human failures are a major cause of breakdowns in upstream facilities because of challenging working conditions. A study of human errors from an incident investigation in upstream facilities was carried out to understand the topography of human errors. A Tripod Beta diagram was developed from 107 incidents gathered during 2017–2020, and the human error taxonomy was used to identify the human errors caused by individuals and contributory human factors responsible for the incidents. A mistake is the most common human failing in a major incident, contributing to 59%, followed by a violation and a skill-based error with scores of 36% and 5%, respectively. Knowledge-based mistakes were prevalent in 48% of the analyzed reports, indicating a significant gap in any decision involving problem-solving and diagnosis. Situational and routine violations with 14% and 10% scoring, respectively, show the complexity of the offshore work environment, which prompts workers to violate and believe that jobs cannot be completed without violations. Disciplinary action, providing a safer workplace, and enhancing the safety culture were proposed to combat workplace violations. Meanwhile, an up-skilling of the workforce with adequate information and instruction will mitigate human errors leading to a mistake. Lastly, revisiting human factor engineering is required to prevent slip and lapse errors.
求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
Process Safety Progress
Process Safety Progress 工程技术-工程:化工
CiteScore
2.20
自引率
10.00%
发文量
99
审稿时长
6-12 weeks
期刊介绍: Process Safety Progress covers process safety for engineering professionals. It addresses such topics as incident investigations/case histories, hazardous chemicals management, hazardous leaks prevention, risk assessment, process hazards evaluation, industrial hygiene, fire and explosion analysis, preventive maintenance, vapor cloud dispersion, and regulatory compliance, training, education, and other areas in process safety and loss prevention, including emerging concerns like plant and/or process security. Papers from the annual Loss Prevention Symposium and other AIChE safety conferences are automatically considered for publication, but unsolicited papers, particularly those addressing process safety issues in emerging technologies and industries are encouraged and evaluated equally.
期刊最新文献
Numerical study of failure modes of hazardous material tanks exposed to fire accidents in the process industry So, you cannot vent: A deep dive into other explosion protection methods Risk and consequence analysis of ammonia storage units in a nuclear fuel cycle facility Diagnosing electrostatic problems and hazards in industrial processes: Case studies Numerical simulation study on propane gas leakage and diffusion law in slope terrain
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
现在去查看 取消
×
提示
确定
0
微信
客服QQ
Book学术公众号 扫码关注我们
反馈
×
意见反馈
请填写您的意见或建议
请填写您的手机或邮箱
已复制链接
已复制链接
快去分享给好友吧!
我知道了
×
扫码分享
扫码分享
Book学术官方微信
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术
文献互助 智能选刊 最新文献 互助须知 联系我们:info@booksci.cn
Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。
Copyright © 2023 Book学术 All rights reserved.
ghs 京公网安备 11010802042870号 京ICP备2023020795号-1