Human Error Model and Definition of Human Reliability

Aim A model of human errors is given. His reliability of action is also determined. Safety countermeasures to prevent human errors are put forward. Methods\ Human system is regarded as a maintainable Markov system. On the basis of Markov method, the deduction and calculation in practice are made. Results\ Human errors are the chief factors leading to accidents, and may appear in different models. There are two kinds of states the normal and error state in a process of work. The process of state transfer human system is a Markov process. Human action reliability will be decreased with the continuation of time. Conclusion\ Human errors are described in the quantified form. It will have some significance in terms of theory in the study of the relationship between human action and accidents. Thus helping us in the preven tion of accident occurrence. The safety of a system can be improved in this way.

Engineering approach for human error probability quantification

A novel approach for engineering application to human error probability quantification is presented based on an overview of the existing human reliability analysis methods. The set of performance shaping factors is classified as two subsets of dominant factors and adjusting factors respectively. Firstly, the dominant factors are used to determine the probabilities of three behavior modes. The basic probability and its interval of human error for each behavior mode are given. Secondly, the basic probability and its interval are modified by the adjusting factors, and the total probability of human error is calculated by a total probability formula. Finally, a simple example is introduced, and the consistency and validity of the presented approach are illustrated.

Formal safety assessment and application of the navigation simulators for preventing human error in ship operations

The International Maritime Organization (IMO) has encouraged its member countries to introduce Formal Safety Assessment (FSA) for ship operations since the end of the last century. FSA can be used through certain formal assessing steps to generate effective recommendations and cautions to control marine risks and improve the safety of ships. On the basis of the brief introduction of FSA, this paper describes the ideas of applying FSA to the prevention of human error in ship operations. It especially discusses the investigation and analysis of the information and data using navigation simulators and puts forward some suggestions for the introduction and development of the FSA research work for safer ship operations.

Causation mechanism of coal miners' human errors in the perspective of life events

In order to effectively decrease the safety accidents caused by coal miners’human errors,this paper probes into the causality between human errors and life events,coping,psychological stress,psychological function,physiological function based on life events’vital influence on human errors,establishing causation mechanism model of coal miners’human errors in the perspective of life events by the researching method of structural equation.The research findings show that life events have significantly positive influence on human errors,with a influential effect value of 0.7945 and a influential effect path of‘‘life events—psychological stress—psychological function—physiological function—human errors’’and‘‘life events—psychological stress—physiological function—human errors’’.

Bayesian estimator of human error probability based on human performance data

A Bayesian method for estimating human error probability（HEP） is presented.The main idea of the method is incorporating human performance data into the HEP estimation process.By integrating human performance data and prior information about human performance together,a more accurate and specific HEP estimation can be achieved.For the time-unrelated task without rigorous time restriction,the HEP estimated by the common-used human reliability analysis（HRA） methods or expert judgments is collected as the source of prior information.And for the time-related task with rigorous time restriction,the human error is expressed as non-response making.Therefore,HEP is the time curve of non-response probability（NRP）.The prior information is collected from system safety and reliability specifications or by expert judgments.The（joint） posterior distribution of HEP or NRP-related parameter（s） is constructed after prior information has been collected.Based on the posterior distribution,the point or interval estimation of HEP/NRP is obtained.Two illustrative examples are introduced to demonstrate the practicality of the aforementioned approach.

An Evaluation of Human Error Probabilities for Critical Failures in Auxiliary Systems of Marine Diesel Engines

Human error,an important factor,may lead to serious results in various operational fields.The human factor plays a critical role in the risks and hazards of the maritime industry.A ship can achieve safe navigation when all operations in the engine room are conducted vigilantly.This paper presents a systematic evaluation of 20 failures in auxiliary systems of marine diesel engines that may be caused by human error.The Cognitive Reliability Error Analysis Method(CREAM)is used to determine the potentiality of human errors in the failures implied thanks to the answers of experts.Using this method,the probabilities of human error on failures were evaluated and the critical ones were emphasized.The measures to be taken for these results will make significant contributions not only to the seafarers but also to the ship owners.

Analysis on the Human Errors in Coal Mines based on Ant Clustering Algorithm

The human error mechanism in coal mine safety is analyzed specifically from safety psychological and physiological factors, worker＇ s quality, safety management, safety education, mechanical equipment, and working environment, and also a human error＇ dominant factors classification model playing a great effect on the safety production of coal mine is established with the application of ant clustering algorithm. The experimental results show that management is the key in the human errors of coal mine.

Human Errors Monitoring in Electrical Transmission Networks

The electrical transmission networks are complex systems that are commonly run near their operational limits. Such systems can undergo major disturbances that have serious consequences. Individually, these disturbances can be attributed to specific causes, such as lightning strikes, ice storms, equipment failure, shorts resulting from untrimmed trees, excessive customer demand, or human errors. In the paper, the human errors from electrical transmission networks of Romanian Power Grid Company over period of 10 years are analyzed. It is hoped that obtained results will provide engineers a better understanding so they can cater to the needs of the human operators when to implement new interfaces for network monitoring tasks, not for the other technical objectives.

Air Traffic Volume and Air Traffic Control Human Errors

Navigable airspaces are becoming more crowded with increasing air traffic, and the number of accidents caused by human errors is increasing. The main objective of this paper is to evaluate the relationship between air traffic volume and human error in air traffic control (ATC). First, the paper identifies categories and elements of ATC human error through a review of existing literature, and a study through interviews and surveys of ATC safety experts. And then the paper presents the results of an experiment conducted on 52 air traffic controllers sampled from the Korean ATC organization to find out if there is any relationship between traffic volume and air traffic controller human errors. An analysis of the experiment clearly showed that several types of ATC human error are influenced by traffic volume. We hope that the paper will make its contribution to aviation safety by providing a realistic basis for securing proper manpower and facility in accordance with the level of air traffic volume.

Method of Estimating Human Error Probabilities in Construction for Structural Reliability Analysis Based on Analytic Hierarchy Process and Failure Likelihood Index Method

Human error(HE) is the most important factor influencing on structural safety because its effect often exceeds the random deviation.Large numbers of facts have shown that structural failures may be caused by the gross error due to HE.So it is essential to analyze HE in construction.The crucial work of human error analysis(HEA) is the estimation of human error probability(HEP) in construction.The method for estimating HEP,analytic hierarchy process and failure likelihood index method(AHP-FLIM),is introduced in this paper.The method also uses the process of expert judgment within the failure likelihood index method(FLIM).A numerical example shows the effectiveness of the methods proposed.

Inspection-Based Policy Considering Human Errors for Three-Stage Delay Time Degradation Systems

A periodic inspection policy for a single component system based on a three-stage failure process is proposed, and two different kinds of failures covering "hard" and "human" are considered in the proposed policy.The system is periodically inspected and inspections are perfect so that they can identify the intended defect.If the severe defect is detected by an inspection, an immediate repair is needed. However, once the system is identified to be in the minor defective state, there are two options. The first is to do nothing till the arrival of identifying the severe defect or hard failure, and the second is to repair immediately. Repair for any defect can renew the system with a limited probability such that the system may fail after repair due to human errors, which is common in many industrial applications. Two models are constructed by minimizing the expected cost per unit time and compared. We provide a numerical example to demonstrate the proposed model.

Software defect prevention based on human error theories

Software defect prevention is an important way to reduce the defect introduction rate.As the primary cause of software defects,human error can be the key to understanding and preventing software defects.This paper proposes a defect prevention approach based on human error mechanisms：DPe HE.The approach includes both knowledge and regulation training in human error prevention.Knowledge training provides programmers with explicit knowledge on why programmers commit errors,what kinds of errors tend to be committed under different circumstances,and how these errors can be prevented.Regulation training further helps programmers to promote the awareness and ability to prevent human errors through practice.The practice is facilitated by a problem solving checklist and a root cause identification checklist.This paper provides a systematic framework that integrates knowledge across disciplines,e.g.,cognitive science,software psychology and software engineering to defend against human errors in software development.Furthermore,we applied this approach in an international company at CMM Level 5 and a software development institution at CMM Level 1 in the Chinese Aviation Industry.The application cases show that the approach is feasible and effective in promoting developers＇ ability to prevent software defects,independent of process maturity levels.

Human Perception of Group Synchronization Error in Remote Learning: Dependencies of Voice and Video Contents in One-Way Communication

This paper examines dependencies of voice and video contents on human perception of group (or inter-destination) synchronization error in remote learning by Quality of Experience (QoE) assessment. In our assessment, we use two videos and three voices (two voices for one video and one voice for the other video). We also investigate influences of silence periods in the voices and temporal relations between the voices and videos (called the tightly-coupled and loosely-coupled contents here). The voices are spoken by a teacher according to the videos. Each subject as a student assesses the group synchronization quality by watching each lecture video and the corresponding explanation voice, and then the subject answers whether he/she perceives the group synchronization error or not. As a result, assessment results illustrate that silence periods mitigate the perception rate of the error, and we can also find that we can more easily perceive the error for tightly-coupled contents than loosely-coupled ones.

改进贝叶斯网络模型在起重作业人机交互差错风险分析中的应用

为量化分析起重作业人机交互差错风险,根据安全工效学原理及安全技术规范将起重作业人、机、环相关影响因素作为根节点,按照事故致因层次关联关系确定子节点,构建起重作业人机交互差错的3层级贝叶斯网络模型(Bayesian Network, BN);基于模糊集理论,采用认知可靠性与失误分析方法(Cognitive Reliability and Error Analysis Method, CREAM),厘定贝叶斯网络父节点失效概率以及中间节点条件概率;利用逆向推理仿真技术分析起重作业人机交互差错发生的因果链,探究起重伤害事故发生的人机交互差错风险。结果表明:起重作业人机交互差错最可能致因链为起重设备安全检查不到位→管理人员失误→人员操作失误→起重伤害事故发生;单因素失效条件下,起重作业人机交互差错风险概率呈线性增长趋势;在多因素失效条件下,一级节点因素失效概率愈大则人机交互差错效应愈显著,且呈现非线性增长态势。

基于组合赋权的压裂作业人因失误概率研究

压裂作业强度大,环境恶劣,长时间枯燥的作业容易诱发人因失误,造成事故,分析压裂现场人因可靠性对于提升压裂作业的安全和效率具有重要意义。在考虑压裂现场情境因素影响基础上,提出了一种组合赋权模糊人因可靠性分析方法,用以评估压裂现场人因失误概率。首先,通过对压裂现场的调研分析,结合压裂作业情境环境特点,基于认知可靠性与失误分析方法(CREAM)建立了适用于评估压裂作业的一级共同绩效条件CPC 8个,二级CPC因子评估指标36个。其次,根据实际工况中各CPC对人的绩效可靠性的影响程度不同,提出以差异系数法确定线性组合系数,基于序关系法与熵权法对各项评估指标进行主客观线性组合赋权。最后,利用本文方法分析四川某页岩气压裂作业现场人因失误概率,结果表明,较一般模糊CREAM方法,在不同情境环境下,随着情境环境水平的下降,组合赋权模糊CREAM方法对CPC评价数据敏感度更高,人因失误概率增加,并且变化速率加快,这与现场实际工况一致,为压裂现场的人因可靠性分析和人因失误概率量化结果优化提供了参考。

智能煤矿下操作人员情境意识影响因素的多面分析

为了探究智能煤矿中导致操作人员情境意识失效的关键因素,构建智能煤矿操作人员情境意识影响因素理论模型。基于428名被试的问卷调查和数据分析,探讨注意力、记忆、环境特性和任务复杂度对情境意识的影响。研究结果表明:注意力资源和工作记忆对情境意识具有直接而显著的影响,而环境特性和任务复杂性则对情境意识有间接影响,总体而言,注意力资源是智能煤矿人因失误风险防范的关键。这些发现可为提高操作人员的情境意识、预防人因失误提供理论依据,有助于指导智能煤矿企业人员培训和系统优化设计。

APPLICATION OF HUMAN COGNITIVE MODEL FOR TIME DEPENDENT OPERATOR BEHAVIOR IN CHINESE NPP

This paper discusses some issues on human reliability model of time dependent human behavior. Some results of the crew reliability experiment on Tsinghua training simulator in China are given, Meanwhile, a case of calculation for human error probability during anticipated transient without scram (ATWS) based on the data drew from the recent experiment is offered.

Human Factor Based Leadership: Critical Leadership Tools to Reduce Burnout and Latent Error in a Time of Accelerating Change

The majority of errors in healthcare are from systems factors that create the latent conditions for error to occur. The majority of occupational stressors causing burnout are also the result of systemic factors. Advances in technology create new levels of stress and expectations on healthcare workers (HCW) with an endless infusion of requirements from multiple authoritative sources that are tracked and monitored. The quality of care and safety of patients is affected by the wellbeing of HCWs who now practice in an environment that has become more complex to navigate, often expending limited neural resource (brainpower) on classifying, organizing, constantly making decisions on how and when they can accomplish what is required(extraneous cognitive load) in addition to direct patient care. New information demonstrates profound biological impact on the brains of those who have burnout in areas that affect the quality and safety of the decisions they make-which affects risk to patients in healthcare. Healthcare administration curriculum currently does not include ways to address these stress-induced problems in healthcare delivery. The science of human factors and ergonomics (HFE) promotes system performance and worker wellbeing. Patient safety is one component of system performance. Since many requirements come without resource to accomplish them, it becomes incumbent upon health system leadership to organize the means for completion of these to minimize the needless loss of brain power diverted away from the delivery of patient care. Human Factor-Based Leadership (HFBL) is an interactive, problem solving seminar series designed for healthcare leaders. The purpose is to provide relevant human factor science to integrate into their leadership and management decisions to make HCWs occupational environment more manageable and sustainable-which makes safer conditions for clinician wellbeing and patient care. After learning the content, a cohort of healthcare leaders believed that adequately addressing HFE in healthcare delivery would significantly reduce clinician burnout and risk of latent errors from upstream leadership decisions. An overview of the content of the seminars is described. Leadership feedback on usability of these seminars is reported. Three HFBL seminars described are Human Factor Relevance in Leadership, Biopsychosocial Approach to Wellness and Burnout, Human Factor Based Leadership: Examples and Applications.

组织视角下的核电厂班组决策失误致因分析

为了系统研究班组决策失误规律,识别核电厂班组决策失误的关键路径,从组织视角出发,结合核电厂所处环境与班组决策失误特征对人因分析与分类系统(Human Factor Analysis and Classification System,HFACS)模型进行改进,建立了核电厂班组决策失误致因模型。利用改进后的模型对137份核电厂事件报告进行统计分析,并运用卡方检验与让步比分析班组决策失误的原因及各层次之间的内在关系。结果表明,组织文化缺失、规程不明晰、知识与能力不足、制定备选方案失误是导致班组决策失误的重要因素。改进HFACS模型中上下层级的因素之间存在显著的因果关系,且容易引发班组决策失误的路径有32条,其中发生概率最大的路径为组织设计不当→任务不明晰→压力过大→确定目标失误。由此可见,核电事故的发生是各致因因素相互作用的结果,降低班组决策失误概率需要阻断关键致因路径,加强对关键因素的管控。