• Title/Summary/Keyword: Human Errors

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SEM-based study on the impact of safety culture on unsafe behaviors in Chinese nuclear power plants

  • Licao Dai;Li Ma;Meihui Zhang;Ziyi Liang
    • Nuclear Engineering and Technology
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    • v.55 no.10
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    • pp.3628-3638
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    • 2023
  • This paper uses 135 Licensed Operator Event Reports (LOER) from Chinese nuclear plants to analyze how safety culture affects unsafe behaviors in nuclear power plants. On the basis of a modified human factors analysis and classification system (HFACS) framework, structural equation model (SEM) is used to explore the relationship between latent variables at various levels. Correlation tests such as chi-square test are used to analyze the path from safety culture to unsafe behaviors. The role of latent error is clarified. The results show that the ratio of latent errors to active errors is 3.4:1. The key path linking safety culture weaknesses to unsafe behaviors is Organizational Processes → Inadequate Supervision → Physical/Technical Environment → Skill-based Errors. The most influential factors on the latent variables at each level in the HFACS framework are Organizational Processes, Inadequate Supervision, Physical Environment, and Skill-based Errors.

Development of a Comprehensive Model for Human Error Prevention in Industrial Fields (산업현장의 휴먼에러 예방을 위한 통합적 분석모델의 개발)

  • Lee, Kwan-Suk;Lim, Hyeon-Kyo;Chang, Seong-Rok;Rhie, Kwang-Won;Kim, Yu-Chang
    • Journal of the Ergonomics Society of Korea
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    • v.27 no.1
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    • pp.37-43
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    • 2008
  • A lot of models have been developed for prevention of human errors. Nevertheless most of them failed to attract attention of industry which has been looking for an integrative model that can show practical countermeasures as well as causal factors of human errors. This research aimed to develop a comprehensive model that can mainly be applied to industrial fields. Therefore, in the model, it was tried to explain sequences of an operator's information process that might cause human errors on one hand, and life cycle stages of facilities involved when human errors occur on the other hand. This model was validated by using a typical accident case. With the comprehensive model presented in this research, one could follow up the sequence of human errors caused by operators, and errors made at the design stage which might cause accidents could be tracked. As a consequence, it is expected that much attention would be paid to preventing human errors in industrial fields since safety personnel can easily find out cause of human errors throughout life cycle stages of man-machine facilities if utilizing the suggested model.

Human Reliability Assessment for a Installation Task of Temporary Power Cables in Construction Fields (건설현장 임시전력 배선의 가설직무에 대한 인간신뢰성 평가)

  • Kim Doo-Hyun;Lee Jong-Ho;Kim Sang-Chul
    • Journal of the Korean Society of Safety
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    • v.20 no.2 s.70
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    • pp.61-66
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    • 2005
  • This paper presents an human reliability assessment(HRA) for a installation task of the temporary power cable in construction fields. HRA is evolved to ensure that the workers could reliably perform critical tasks such as a process of the temporary power cable. Human errors are extremely commonplace, with almost everyone committing at least some errors every day. The considerable parts of electric shock accidents in the construction field are caused by a series of human errors. Therefore it is required to analyze the human errors contained in the task causing electric shock event, the event tree analysis(ETA) is adopted in this paper, and particularly human reliability was estimated for a installation task of the temporary power cables. It was assumed that the error probabilities of the human actions may be obtained using the technique for human error rate prediction(THERP). The results show that the predominant task on reliability in the cable installation tasks is check-out tasks and the probability causing electric shock by human errors was calculated as $1.0\times10^{-9}$.

A Study on FSA Application for Human Errors of Dynamic Positioning Vessels Incidents

  • Chae, Chong-Ju
    • Journal of Navigation and Port Research
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    • v.41 no.5
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    • pp.259-268
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    • 2017
  • Formal Safety Assessment (FSA) has been mostly implemented on the hardware aspects of vessels. Although there are guidelines regarding human error FSAs, there have not been many assessments in such areas. To this end, this study seeks to use precedent studies for the safe operation of DP vessels, conducting an FSA regarding human error of DP LOP (Loss of Position) incidents. For this, the study referred to precedent studies for the frequency of DP LOP incidents caused by human errors, adding the severity of LOP incidents, and then applying them to the Bayesian network. As a result, the study was able to confirm that among DP LOP incidents caused by human errors, the drive-off from skill-based errors was 74.3% and the drive-off from unsafe supervision was 50.5%. Based on such results, RCOs (Risk Control Options) were devised through a brainstorming session with experts coming up with proposals including providing mandatory DPO training, installing DP simulator on the vessels, drawing up measures to understanding the procedures for safe operation of DP vessels. Moreover, it was found that mandatory DPO training is reasonable in terms of cost benefits and that while installing a DP simulator is not suitable in terms of cost benefits, it can significantly reduce risks when operating DP vessels.

An Investigation of Human Error Analysis Techniques in Various Industries with Implications for the Korean Railway Industry (인적오류 분석기법의 국내외 활용 현황 및 국내 철도 산업에의 적용 방안)

  • Baek, Dong-Hyun;Yoon, Wan-Chul;Kim, Dong-San
    • Journal of the Korean Society for Railway
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    • v.10 no.1 s.38
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    • pp.7-15
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    • 2007
  • Since human errors are being recognized as one of the primary issues in railway safety, there is a definite need for human error analysis techniques that can identify the types of errors and their causes and derive effective countermeasures to help reduce their future probability. But, for some reasons, there are not yet systematic procedures or techniques for analyzing human errors in the Korean railway industry. This paper introduces several techniques that have been developed and utilized for analyzing human errors in Korean and overseas nuclear power aviation railway, offshore oil industry, etc., and summarizes the strengths and weaknesses of each technique. Based on the Investigation of the techniques, the paper also discusses the implications for the development of a human error analysis system for the Korean railway industry.

Validation of the Effectiveness of Education for Obtaining Consent in Clinical Study (임상연구 동의서 교육 시행의 효용성 검증)

  • Ji Eun Kim;Mi Sung Lee;Sul Hwa Kim;Ji Hye Yang;Seung Ah Go;Cho Long Lee;Soo Yeon Yang;Hae Joo Shin;Bo Ah Kim;Jong Woo Chung
    • The Journal of KAIRB
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    • v.5 no.2
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    • pp.51-58
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    • 2023
  • Purpose: To validate the effectiveness of obtaining consent education on errors in the consent process and to develop the education program for researchers. Methods: From February 2019 to February 2022, a 30-minute, 1:1 face-to-face consent education developed using the ADDIE model was conducted on 78 nurses as principal investigators. An informed consent audit tool, which includes 6 items developed by Asan Medical Center Human Research Protection Center, was used to analyze errors in obtaining informed consent process. Data analysis was performed using the SPSS ver. 25.0, and the Mann-Whitney U-test and χ2-test were utilized to verify the difference in errors between the experimental and control groups. Results: The participants consisted of 42 in the experimental group and 36 in the control group, with no statistically significant difference between the 2 groups. Both 2 groups showed the highest frequency of documentation errors, followed by format errors, errors related to a suitability of investigator, participant, or participant's legally acceptable representative, witness and confidentiality issues. After education, there was a significant decrease in both format errors (p=0.002) and documentation errors (p<0.001) in the experimental group. The proportion of participants without any errors in all items was higher in the experimental group (35.7%) compared to the control group (5.6%), and this difference was statistically significant (p=0.001). Conclusion: The obtaining consent education program was found to be effective in reducing informed consent errors. This study emphasizes the importance of education, suggesting the need for its expansion and accessibility, as well as the necessity for all researchers conducting clinical studies to receive the obtaining consent education.

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Cognitive Analysis on Accident-related Human Factors during Shunting Movements (철도 입환작업 중의 인적 사고요인에 대한 인지과학적 분석)

  • Lee, Seung-Won;Lim, Hyeon-Kyo
    • Journal of the Korean Society of Safety
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    • v.20 no.4 s.72
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    • pp.114-121
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    • 2005
  • Railroad shunting movements connecting and disconnecting train sets are very susceptible to human errors since they depend on human decision-making and action procedure that are variable to situation to situation. Nevertheless, in the investigation of railroad accidents, all the accident causes related with human factors have merely been categorized as 'careless treatment' of the workers without any systematic approach of behavioral sciences or the analysis of human errors. In this research, therefore, 137 accident cases occurred during railroad shunting movements and 435 accident cases occurred during driving were analyzed with a special interest of human errors. According to results, the traditional accident investigation scheme used for last several decades did not seem to be appropriate for catching up true accident causes with respect to human errors. In addition, both signal men and locomotive drivers made many mistakes in judgement/action stage while the former mainly commit judgement tasks where as the latter mainly commit cognition tasks. Ant those tasks such as 'confirmation of signal and route', 'location check-up of connected train sets', and 'route identification for a shift of track' ranked highly for accident susceptibility.

Task Types and Loads of Railway Worker (열차운용원의 직무유형 및 직무부하)

  • Han, Kyu-Min;Ko, Jong-Hyun;Jung, Won-Dea;Kang, Jung-Seok
    • Proceedings of the KSR Conference
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    • 2007.05a
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    • pp.1204-1208
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    • 2007
  • In order to prevent railway accidents due to human errors which have been recognized to be the most important cause in the railway accidents, human errors should have been controlled based on systematical analysis of the human errors, and countermeasures should be derived to reduce human error probability. Among several factors inducing human errors, task load (or task complexity) is representative. In order to reduce the human error, a systematic analysis should be undertaken to evaluate task load. In this study, task load according to task types of railway worker who are a safety critical staff have been quantitatively analyzed based on NASA-TLX(Task Load Index).

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Study on Application of Critiquing System As Corresponding Plan of Human Errors on Judgment Process (판단과정에 따른 인간 실수 대응을 위한 비판시스템의 적용방안에 관한 연구)

  • Yoon, Ho-Bin;Kang, Kyung-Sik
    • Journal of the Korea Safety Management & Science
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    • v.10 no.1
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    • pp.11-22
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    • 2008
  • Humans are well-known for being adept at using intuition and expertise in many situations. However, human experts are still susceptible to errors in judgment or execution, and failure to recognize the limits of knowledge. This would happen especially in semi-structured situations, in multi-disciplinary settings, under time or other stress, under uncertainty, or when knowledge is outdated Human errors are caused by cognitive biases, attentional slips/memory lapses, cultural motivations, and missing knowledge. The purpose of this research is to study errors of human experts committed in judgment and the general idea of critiquing systems as corresponding plan. Compared to expert systems, critiquing systems are narrowly focused programs useful in limited situations for collaborating with and supporting experts in their task activities. It supports an expert by detecting the human's errors by deploying various strategies that stimulate humans to improve their performance. A variety of types of critiquing systems has spread through numerous application areas.

Effort and Development Direction of Aviation Organization Against Human Errors (인적오류에 대응하는 항공분야의 노력과 발전방향)

  • Kim, Dae-Ho
    • Journal of the Ergonomics Society of Korea
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    • v.30 no.1
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    • pp.29-39
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    • 2011
  • Safety management paradigm which against human errors in aviation industry is now changing from the follow-up measures after accident in the past to systematic approach that a forecast the hazards and improve the working system of the group to prevent accidents. As human factors are based on the man's specific psychological traits, it takes much time and efforts to prepare the preventive measures. That's why aviation industry is interested in the accident-prevent measurements against human errors. In this thesis, therefore, we are going to introduce the efforts that aviation organizations have tried and recommend management systems and discuss the suggestive facts. At first, we discussed introduction of HFACS which is the systematic accidents-classification system related to human errors in the aviation organization and countermeasure in the aspects of management, technology/engineering, education training. We described about FOQA, LOSA, CRM/TEM, aviation safety information DB in the aspect of management, and explained safety technologies that prevent human errors or avoid technologically when emergency occurs in the aspect of technology/engineering. In the aspect of education training, we explained the application plan about safety programs(LOFT/Simulator use, CRM/TEM application etc).