Volume 7, Issue 4 (12-2011)
J Health Syst Res 2011, 7(4): 0-0 |
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Habibi E A, Gharib S A, Mohammadfam I, Rismanchian M. Human Error Assessment and Management among Isfahan, Iran Oil
Refinery Control Room Operators by SHERPA Technique. J Health Syst Res 2011; 7 (4)
URL: http://hsr.mui.ac.ir/article-1-270-en.html
URL: http://hsr.mui.ac.ir/article-1-270-en.html
1- Associate Professor, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
2- MSc Student, Student Research Committee, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Virtual Institute of HSE, Basij Organization of Medicine Society, Tehran, Iran.
3- Assistant Professor, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
4- Lecturer, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
2- MSc Student, Student Research Committee, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Virtual Institute of HSE, Basij Organization of Medicine Society, Tehran, Iran.
3- Assistant Professor, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran.
4- Lecturer, Department of Professional Health, School of Health, Isfahan University of Medical Sciences, Isfahan, Iran
Abstract: (1685 Views)
Introduction: In many work environments with sensitive and complex technologies, human errors are very important since they may lead to catastrophes. Therefore, it is necessary to recognize and find out causes of human errors to prevent and limit their dreadful consequences. This study aimed to identify, assess and control human errors in the distillation unit of Isfahan Oil Refinery. Methods: This study was performed in 2010. Data was collected using task observation and interviewing safety authorities, unit and shift supervisors and operators. Finally, 8 critical tasks were determined. Then, Hierarchical Task Analysis (HTA) was conducted and human errors in each task were identified by Systematic Human Error Reduction Prediction Approach (SHERPA) technique. Results: After analyzing SHERPA work sheets, 198 human errors were identified including 134 (67.64%) action errors, 23 (11.61%) checking errors, 11 (5.6%) communication errors, 24 (12.12%) retrieval errors and 6 (3.03%) selection errors. Overall, the possibility of 64% of human errors among control room operators was assessed as "low" while 36% had a "moderate" possibility. In addition, although 59% of the identified errors of control room operators required no recovery, 29% resulted in sensitive outcomes. Conclusion: The results showed that SHERPA technique can be used as an effective method to detect human errors in the control room of sensitive units of oil refineries.
Type of Study: Research |
Subject:
education health and promotion
Received: 2020/07/16 | Accepted: 2011/12/15 | Published: 2011/12/15
Received: 2020/07/16 | Accepted: 2011/12/15 | Published: 2011/12/15
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