Volume 3, Issue 4 (Winter 2017)                   johe 2017, 3(4): 22-30 | Back to browse issues page

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Azhdari M, Monazami Tehrani G, Alibabaei A. Investigating the causes of human error-induced incidents in the maintenance operations of petrochemical industry by using HFACS. johe 2017; 3 (4) :22-30
URL: http://johe.umsha.ac.ir/article-1-220-en.html
Investigating the causes of human error-induced incidents in the maintenance operations of petrochemical industry by using HFACS
Mohammadreza Azhdari1 , Ghazaleh Monazami Tehrani * 2, Ahmad Alibabaei3
1- Zagros Petrochemical Company
2- Department of Industrial Safety, School of Health, Safety and Environment, Shahid Beheshti Medical University of Science , ghazaltehrani27@gmail.com
3- Department of Industrial Safety, School of Health, Safety and Environment, Shahid Beheshti Medical University of Science
Abstract:   (8581 Views)

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.

Keywords: human error, petrochemical industry, maintenance, HFACS
Full-Text [PDF 323 kb]   (5023 Downloads)    
Type of Study: Research Article | Subject: Safety
References
1. [Human error is one of the main causes of recent accidents in petrochemical industry]. 2015. Available at: http://www.shana.ir/fa/newsagency/267236 Accessed Aug 20, 2015.[Persian]
2. Peng G. "On the human error in maintenance: risk potential and mitigation." MSC Thesis, University of Stavanger, 2014.
3. Reinach S, Viale A. Application of a human error framework to conduct train accident/incident investigations. Accident Analysis and Prevention. 2006; 38: 396-406. [DOI:10.1016/j.aap.2005.10.013] [PMID]
4. Jahangiri M, Hoboubi N. Human error analysis in a permit to work system: a case study in a chemical plant. Safety and Health at Work. 2016 Mar; 7(1): 6-11. [DOI:10.1016/j.shaw.2015.06.002] [PMID] [PMCID]
5. Attwood D, Deeb J, Danz-Reece M. Ergonomic solutions for the process industries. 1sted. New York: Elsevier; 2004.
6. Hu W, Meyer J. Dynamic data driven approach for modeling human error. Procedia Computer Science. 2015; 51: 1643-1654. [DOI:10.1016/j.procs.2015.05.298]
7. Mahdavi S, Farsani E.H, Taajvar A. [Identification and assessment of human error due to design in petroleum refinery sour water equipment damage by SHERPA]. Journal of Health and Safety at Work. 2013 Feb; 2(4): 61-70. [Persian]
8. Khosravirad F, Zarei E, Mohammadfam I, Shoja E. [Analysis of Root Causes of Major Process Accident in Town Border Stations (TBS) using Functional Hazard Analysis (FuHA) and Bow tie Methods]. Journal of Occupational Hygiene Engineering. 2014; 1(3):19-28. [Persian]
9. Karimi S, Mirzaei Aliabadi M, Mohammad fam I. [Using SHERPA to identify and assess human errors during blasting in an iron ore mine]. Journal of Occupational Hygiene Engineering. 2015; 2(1):57-65. [Persian]
10. Omidvari M, Garmaroudi M.R. [Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms]. Journal of Health and Safety at Work. 2015 Aug; 5(3): 1-12. [Persian]
11. Shirali G.A, Karami E, Goodarzi Z. [Human errors identification using the human factors analysis and classification system technique (HFACS)]. Journal of Health and Safety at Work. 2013 Nov; 3(3): 45-54. [Persian]
12. Chiu M, Hsieh M, Latent human error analysis and efficient improvement strategies by fuzzy TOPSIS in aviation maintenance tasks. Applied Ergonomics. 2016 May; 54: 136–147. [DOI:10.1016/j.apergo.2015.11.017] [PMID]
13. Omole H, Walker G. Offshore transport accident analysis using HFACS. Procedia Manufacturing. 2015 Oct; 3: 1264-1272. [DOI:10.1016/j.promfg.2015.07.270]
14. Ergai A, Cohen T, Sharp J, Doug W, Gramopadhye A, Shappell S. Assessment of the human factors analysis and classification system (HFACS): Intra-rater and inter-rater reliability. Safety Science. 2016 Feb; 82: 393–398. [DOI:10.1016/j.ssci.2015.09.028]
15. Ancel E, Shih A.T. The analysis of the contribution of human factors to the in-flight loss of control accidents. 12th AIAA Aviation Technology, Integration, and Operations (ATIO) Conference and 14th AIAA/ISSMO Multidisciplinary Analysis and Optimization Conference 2012 Sep; Indianapolis, India.
16. Rashid H.S.J, Place C.S, Braithwaite G.R. Helicopter maintenance error analysis: Beyond the third order of the HFACS-ME. International Journal of Industrial Ergonomics. 2010 Nov; 40(6): 636-647. [DOI:10.1016/j.ergon.2010.04.005]
17. Dekker W. A, Sidney. Ten questions about human error a new view of human factor and system safety. New Jersey. 2005.
18. Krulak D.C. Human factors in maintenance: impact on aircraft mishap frequency and severity. Aviation, Space and Environmental Medicine, 2004; 75(5), 429-432. [PMID]
19. Health and Safety Executive. Improving maintenance a guide to reducing human error. UK: The Institute; 2000.
20. Maintenance Human Factors Boeing Commercial Aviation Services. Maintenance Error Decision Aid (MEDA) User's Guide. Chicago: Boeing; 2013.
21. Gong Y, Fan Y. Applying HFACS approach to accident analysis in petro-chemical industry in China: Case study of explosion at bi-benzene plant in Jilin. Advances in Intelligent Systems and Computing. 2016 Jul; 491: 399-406. [DOI:10.1007/978-3-319-41929-9_37]
22. Patterson J.M, Shappell S.A. Operator error and system deficiencies: Analysis of 508 mining incidents and accidents from Queensland, Australia using HFACS. Accident Analysis and Prevention. 2010 Jul; 42(4): 1379-1385. [DOI:10.1016/j.aap.2010.02.018] [PMID]
23. Ting L.Y.A, Dai D.M.B. The identification of human errors leading to accidents for improving aviation safety. International IEEE Conference on Intelligent Transportation System. 2011; 38 - 43. [DOI:10.1109/ITSC.2011.6082851]
24. Celik M, Cebi S. Analytical HFACS for investigating human errors in shipping accidents. Accident Analysis and Prevention. 2009; 41: 66-75. [DOI:10.1016/j.aap.2008.09.004] [PMID]
25. Mohammadfam I, Ghasemi F, Kalatpour O, Moghimbeigi A. Constructing a bayesian network model for improving safety behavior of employees at workplaces. Applied Ergonomics.2017; 58: 35-47. [DOI:10.1016/j.apergo.2016.05.006] [PMID]
26. Ghasemi A, Atabi F, Golbabaei F. [Human Error Classification for the Permit to Work System by SHERPA in a Petrochemical Industry]. 2015; 2(3): 56-73. [Persian]
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