Study of human error from incident investigation in upstream facilities

IF 1 4区 工程技术 Q4 ENGINEERING, CHEMICAL
Abdul Hafiz Abd Halim, Tinia Idaty Mohd Ghazi, Faizah Mohd Yassin, Mohd Zahirasri Mohd Tohir
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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.
上游设施事故调查中的人为错误研究
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。
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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.
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