تحلیل عوامل انسانی موثر بر بروز خطا در فرایندهای عملیاتی: مطالعه موردی یک شرکت گاز

Analysis of human factors influencing errors in operational processes: Case study A Gas Company


چاپ صفحه
پژوهان
صفحه نخست سامانه
مجری و همکاران
مجری و همکاران
منابع
منابع
علوم پزشکی شهید بهشتی
علوم پزشکی شهید بهشتی

مجریان: رضا غلام نیا , سارا برون

کلمات کلیدی: خطای انسانی - عوامل انسانی-HFACS-HEART-علت حادثه-آنالیز حوادث-صنعت نفت و گاز

اطلاعات کلی طرح
hide/show

کد طرح 17443
عنوان فارسی طرح تحلیل عوامل انسانی موثر بر بروز خطا در فرایندهای عملیاتی: مطالعه موردی یک شرکت گاز
عنوان لاتین طرح Analysis of human factors influencing errors in operational processes: Case study A Gas Company
کلمات کلیدی خطای انسانی - عوامل انسانی-HFACS-HEART-علت حادثه-آنالیز حوادث-صنعت نفت و گاز
نوع طرح کاربردی
نوع مطالعه مقطعی
مدت اجراء - روز 180
ضرورت انجام تحقیق

صنایع فرایندی حوادث ویرانگری را تجربه کرده است و آمارها نشان داده اند که بیشتر این موارد به عوامل انسانی مربوط می شود.مطالعات نشان داده اند که برخی از تصمیمات اتخاذ شده و اقدامات صورت گرفته به اندازه کافی اثربخش نبودند  تا از وقوع حادثه به خصوص در صنایع مستعد خطرات و حوادث پیشگیری کنند.یکی از مشخصه های صنایع مهمی همچون نفت و گاز این است که میزان قابل توجهی از مواد خطرناک و بخش وسیعی از تجهیزات پیچیده تحت کنترل و سرویس چند نفر اپراتورمی باشد.مطالعات اخیر متمرکز بر خطاهای انسانی نشان داده است که عواملی مثل فرهنگ سازمانی و نظارت از جمله عوامل موثر بر وقوع حوادث بوده اند.خطاهای انسانی علاوه بر ویژگی های روانی انسان، به ویژگی های ابزارها و وظایف اپراتورها بستگی داشته و بر این اساس عوامل سازمانی در بروز خطاهای انسانی نقش بسزایی دارد.

هدف کلی تحلیل عوامل انسانی موثر بر بروز خطا در فرایندهای عملیاتی: مطالعه موردی در شرکت گاز
خلاصه روش کار

روش انجام این تحقیق طی مراحل زیر انجام خواهد شد:

1)تشکیل تیم تحقیق که متشکل از 7 نفر است وکلیه مراحل انجام تحقیق با همکاری و توافق نظر گروهی آنها انجام خواهد شد.

2)دریافت و بررسی مستندات و گزارش حوادث

3)دریافت و بررسی استانداردها، دستورالعمل ها و روش های اجرایی موجود

4)بررسی و آنالیز مستندات و اطلاعات جمع آوری شده با استفاده از روش HFACS-OGI

5)بررسی و آنالیز مستندات و اطلاعات جمع آوری شده با استفاده از روش HEART

6)تجزیه و تحلیل داده ها

7)کمی سازی و اولویت بندی عوامل انسانی موثر بر بروز خطا

8)تعیین اقدامات اصلاحی مناسب بر اساس اصول ارگونومی سازمانی جهت عملکرد انسانی


اطلاعات مجری و همکاران
hide/show

نام و نام‌خانوادگی سمت در طرح نوع همکاری درجه‌تحصیلی پست الکترونیک
رضا غلام نیامجری اصلی دکتری حرفه ایreza_gholamnia@yahoo.com
موسی جباری قره باغهمکار دکترای تخصصی پی اچ دیmousaja@yahoo.com
سارا برونمجری لیسانسsara_boroun@yahoo.com

منابع
hide/show

[1]. Kariuki SG, Löwe K. Integrating human factors into process hazard analysis. Reliab Eng Syst Saf 2007;92:1764–73.

 [2]. Manca D, Brambilla S. Dynamic simulation of the BP Texas City refinery accident. J Loss Prev Process Ind 2012;25:950–7.

[3]. Mishra KB. CFD model for large hazardous dense cloud spread predictions, with par- ticular reference to Bhopal disaster. Atmos Environ 2015;117:74–91.

 [4] Venart JES. Flixborough: the explosion and its aftermath. Process Saf Environ Prot 2004;82:105–27.

 [5]. The U.S. Chemical Safety Board. Giant industries refinery explosions and fire —investigations | the U.S. Chemical Safety Board 2005. http://www.csb.gov/ giant- industries- refinery- explosions- and- fire/

[6] Singh B, Jukes P, Poblete B, Wittkower B. 20 years on lessons learned from Piper Alpha. The evolution of concurrent and inherently safe design. J Loss Prev Process Ind 2010;23:936–53.

[7].Boschee P. Improving Human Performance: Tackling the Challenges to Develop Effective Safety Cultures. Oil and Gas Facilities. 2014 Jun 1;3(03):18-23.

[8].Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human erroranalysis among petrochemical plant control room operators with human error assessment and reduction technique. Iran Occupat Health. 2009;6(2):38-50.

[9].Shirali GA, Karami E, Goodarzi Z. [Human errors identification using the human factors analysis and classification system technique (HFACS)]. J Health Saf Work. 2013;3(3):45-54.

[10]Diehl A. The effectiveness of training programs for preventing aircrew'error'. 6th ed. Columbus, OH: International Symposium on Aviation Psychology; 1991.

[11]Jensen RS. The boundaries of aviation psychology, human factors, aeronautical decision making, situation awareness, and crew resource management. Int J Aviation Psychol. 1997;7(4):259-67.

[12].Dekker S. Ten Questions about Human Error: A New View of Human Factors and System Safety. New Jersey: Taylor & Francis; 2005.

[13].Vahedian-Shahroodi M, Mohammadi F, Tehrani H. A review of studies in the field of knowledge and safe behaviors of workers in Iran. Journal of Health Literacy. 2016;1(1):25-38

[14].Majd MM, Gorgi AB. A Study of the Social Construction of Work-Related Accidents “A Case study&58; workers of the coal mines of Koohbanan in Kerman and Tabas”. Interdisciplinary Studies in the Humanities. 2015 Jan 1;7(2):101-26.

[15].Mullen J. Investigating factors that influence individual safety behavior at work. Journal of safety research. 2004 Jan 1;35(3):275-85.

[16].Mearns K, Whitaker SM, Flin R. Safety climate, safety management practice and safety performance in offshore environments. Safety science. 2003 Oct 1;41(8):641-80.

[17]. Zohar D, Luria G. Climate as a social-cognitive construction of supervisory safety practices: scripts as proxy of behavior patterns. Journal of applied psychology. 2004 Apr;89(2):322.

[18] .Taheri Sh, Work Measurement a Method Study, Tehran:Arvin; 1999.[In Persian].

[19] .Helander M. A Guide to the Ergonomics of Manufacturing. London: Taylor & Francis; 1995.

[20]Kirwan B. A guide to practical human reliability assessment. Bristol: Taylor & Francis; 1994.

[21] Crowl DA, Louvar JF. Chemical process safety: fundamentals with applications. 3rd ed. Upper Saddle River: Prentice Hall; 2011. P. 520-2.

[22] Kabiri Q. Foundations of organizational behavior. Tehran: Islamic Azad University Science; 2001. [In Persian].

[23]Kiani F, Samavatyan H, Poorabdian S, Mansournejad Z, Jafari E. Effectiveness of a safety training course in changing employees' attitude toward safety issues and its dimensions: a pathological study. Journal of School of Public Health & Institute of Public Health Research. 2011 Jul 1;9(2).

[24]Fam IM, Kianfar AL, Mahmoudi S. Evaluation of relationship between job stress and unsafe acts with occupational accident rates in a vehicle manufacturing in Iran. International Journal of Occupational Hygiene. 2010;2(2):85-90.

[25] Chau N, Mur JM, Benamghar L, Siegfried C, Dangelzer JL, Francais M, Jacquin R, Sourdot A. Relationships between Some Individual Characteristics and Occupational Accidents in the Construction Industry: A Case-Control Study on 880 Victims of Accidents Occurred during a Two-Year Period. Journal of occupational health. 2002;44(3):131-9.

[26] Salminen S, Gyekye SA, Ojajarvi A. Individual and organizational factors of safe behaviour among Ghanaian industrial workers. Engineering Management Research. 2013 Apr 28;2(1):98.

[27] Stride CB, Turner N, Hershcovis MS, Reich TC, Clegg CW, Murphy P. Negative safety events as correlates of work-safety tension. Safety science. 2013 Mar 1;53:45-50.

[28] Theophilus SC, Bassey BO, Ajare TO, Baroni AS, Odigie OP, Asogwa D. Fifteen-Year Accident Causation Assessment of the Petroleum Industry in South and Central America Using Statistical Correlations. InSPE African Health, Safety, Security, Environment, and Social Responsibility Conference and Exhibition 2016 Oct 4. Society of Petroleum Engineers.

 [29] De Felice, F.& Petrillo, A.(2011). Methodological for Performing Human Reliability and Error Analysis in Railway Transportation System.International Jornal of Engineering and Technology, Vol.3 (5), 341-353.

[30] Theophilus SC, Bassey BO, Ajare TO, Baroni AS, Odigie OP, Asogwa D. Fifteen-Year Accident Causation Assessment of the Petroleum Industry in South and Central America Using Statistical Correlations. InSPE African Health, Safety, Security, Environment, and Social Responsibility Conference and Exhibition 2016 Oct 4. Society of Petroleum Engineers.

 [31] Goetsch D. L. Occupational Safety and Health for Technologists, Engineers, and Managers. (2011) : 7th edn. London:Pearson.

[32] Patel, M., Sherratt, F., and Farrell, P. (2012) ‘Exploring Human Error through the Safety Talk of Utilities Distribution Operatives’. in Procs 28th Annual ARCOM Conference. ed. by Smith, S. D. Edinburgh: Association of Researchers in Construction Management, 403–412.

[33].Theophilus SC, Shaibu JH. Assessing leadership and employee safety participation in managing health and safety: a case study of K-Refinery and Petrochemical Compa- nies (K-RPC). In: Energy Sustain. V, vol. 206. Putrajaya, Malaysia: WIT Press; 2014. p. 69–79.

 [34].Pasman HJ, Knegtering B, Rogers WJ. A holistic approach to control process safety risks: Possible ways forward. Reliab Eng Syst Saf 2013;117:21–9.

[35] IOGP (2014) Safety Performance Indicators - 2013 Data (OGP Data Series). United Kingdom: International Association of Oil and Gas Producers.

[36] Attwood D, Khan F, Veitch B. Offshore oil and gas occupational accidents—What is important?. Journal of loss prevention in the process industries. 2006 Sep 1;19(5):386-98.

[37] Graham I. Working conditions of contract workers in the oil and gas industries. ILO; 2010.

[38] Sutton, I. (2013) Offshore Safety Management: Implementing a SEMS Program (2nd Edition) [online] Binghamton, NY,USA: William Andrew.available from http://site.ebrary.com/lib/coventry/docdetail.action?docid=10812570&ppg=1

[39].Kirwan, B.: The validation of three Human Reliability Quantification techniques- THERAP, HEART, and JHDI: Part 1-technique descriptions and validation issues. Appl. Ergon. 27, 359–373 (1996).

[40] Theophilus SC, Shaibu JH. Assessing leadership and employee safety participation in managing health and safety: a case study of K-Refinery and Petrochemical Compa- nies (K-RPC). In: Energy Sustain. V, vol. 206. Putrajaya, Malaysia: WIT Press; 2014.

 [41] Pasman HJ, Knegtering B, Rogers WJ. A holistic approach to control process safety risks: Possible ways forward. Reliab Eng Syst Saf 2013;117:21–9.

 [42] Knegtering B, Pasman HJ. Safety of the process industries in the 21st century: a changing need of process safety management for a changing industry. J Loss Prev Process Ind 2009;22:162–8.

[43] Kidam K, Hurme M. Analysis of equipment failures as contributors to chemical pro- cess accidents. Process Saf Environ Prot 2013;91:61–78.

 [44] O’Dea A, Flin R. Site managers and safety leadership in the offshore oil and gas industry. Saf Sci 2001;37:39–57.

[45] Reinach S, Viale A. Application of a human error framework to conduct train acci- dent/incident investigations. Accid Anal Prev 2006;38:396–406.

[46].Stephen Chukwubikem Theophilusm,Victor Nsikan Esenowo,Andrew Oyen Arewa,Augustine Osamor Ifelebuegu,Ernest Okwudiri Nnadi,Fredrick Uzodinma Mbanaso:Human factors analysis and classification system for the oil and gas industry(HFACS-OGI).Reliability Engineering and System Safety167(2017)168-176.

[47]. Stamatelatos M, Dezfuli H, Apostolakis G,Everline C, Guarro S, Mathias D, et al. Probabilistic

risk assessment procedures guide for NASA managers and practitioners. 2011.

[48]. Hollnagel E. Human reliability assessment in context. Nuclear Engineering and Technology. 2005;37(2):159.

[49]. Maguire R. Validating a process for understanding human error probabilities in complex human computer interfaces. Complexity in Design  and Engineering. 2005:313-26.

 [50] Alexander TM. Human Error Assessment and Reduction Technique (HEART) and Human Factor Analysis and Classification System (HFACS).

[51].Stephen Chukwubikem Theophilusm,Victor Nsikan Esenowo,Andrew Oyen Arewa,Augustine Osamor Ifelebuegu,Ernest Okwudiri Nnadi,Fredrick Uzodinma Mbanaso:Human factors analysis and classification system for the oil and gas industry(HFACS-OGI).Reliability Engineering and System Safety167(2017)168-176.

[52]Shirali G, Jahani F, Shakib M, Mir I. Identification and Evaluation of Human Errors leading to incidents in a gas refineries using Human Factors Analysis and Classification System: Case study gas refinery. Journal of Occupational Hygiene Engineering. 2018 Jan 15;4(4):1-1.

[53] 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. Journal of Occupational Hygiene Engineering. 2017 Mar 15;3(4):22-30.

[54] Ludfi Pratiwi Bowo(&) and Masao Furusho:A Comparison of the Common Causes of Maritime Accidents in Canada, Indonesia, Japan, Australia, and England: Springer International Publishing AG, part of Springer Nature 2019 R. L. Boring (Ed.): AHFE 2018, AISC 778, pp. 256–267, 2019.

[55] Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human erroranalysis among petrochemical plant control room operators with human errorassessment and reduction technique. Iran Occupat Health. 2009;6(2):38-50.

[56] Castiglia F, Giardina M. Analysis of operator human errors in hydrogen refuelling stations: comparison between human rate assessment techniques. international journal of hydrogen energy. 2013 Jan 24;38(2):1166-76.

[57] Kumar AM, Rajakarunakaran S, Prabhu VA. Application of fuzzy heart and expert elicitation for quantifying human error probabilities in lpg refuelling station. Journal of Loss Prevention in the Process Industries. 2017 Jul 1;48:186-98.

[58]Omole H, Walker G. Offshore Transport Accident Analysis Using HFACS. Procedia Manuf. 2015;3:1264-72.

[59] Rashid HS, Place CS, Braithwaite GR. Helicopter maintenance error analysis: Beyond the third order of the HFACS-ME. International Journal of Industrial Ergonomics. 2010 Nov 1;40(6):636-47.

[60] Ergai A, Cohen T, Sharp J, Wiegmann D, Gramopadhye A, Shappell S. Assessment of the Human Factors Analysis and Classification System (HFACS): Intra-rater and inter-rater reliability. Saf Sci. 2016;82:393-8.

[61] Pakdel E, OMIDVARI M. Investigating the Effects of Human Personality on Human Reliability and Accident Frequency Using DISC and HEART Technique in Automotive Industries. J Ergo 2016;5(1):26-35.

[62]Johnson C. Why human error modeling has failed to help systems development. Interact Comput. 1999;11:517–524

 [63].Hu W-L, Meyer JJ, Wang Z, Reid T, Adams DE, Prabnakar S, et al. Dynamic Data Driven Approach for Modeling Human Error. P[28].Omidvari M, Garmaroudi MR. [Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms]. J Health Saf Work. 2015;5(3):1-12.

 [64] Omidvari M, Garmaroudi MR. [Analysis of human error in occupational accidents in the power plant industries using combining innovative FTA and meta-heuristic algorithms]. J Health Saf Work. 2015;5(3):1-12.

[65] O’Dea A, Flin R. Site managers and safety leadership in the offshore oil and gas industry. Saf Sci 2001;37:39–57.  

 [66] Shirali GA, Karami E, Goodarzi Z. Human errors identification using the human factors analysis and classification system technique (HFACS). Health and Safety at Work. 2013 Dec 15;3(3):45-54.

[67] 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]. J Occup Hyg Eng. 2014;1(3):19-28.

[68]Kirwan, B.: The validation of three Human Reliability Quantification techniques- THERAP,HEART, and JHDI: Part 1-technique descriptions and validation issues. Appl. Ergon.1996: 27,359–373.

[69]Akyuz E, Celik M, Cebi S. A phase of comprehensive research to determine marine-specific EPC values in human error assessment and reduction technique. Safety science. 2016 Aug 1;87:63-75