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}
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.
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.