Conventionally, all the unsafe acts by human beings in relation to industrial accidents have been regarded as unintentional human errors. Exceptionally, however, in the cases with fatalities, seriously injured workers, and/or losses that evoked social issues, attention was paid to violating related laws and regulations for finding out some people to be prosecuted and given judicial punishments. As Heinrich stated, injury or loss in an accident is quite a random variable, so it can be unfair to utilize it as a criterion for prosecution or punishment. The present study was conducted to comprehend how categorizing intentional violations in unsafe acts might disrupt conventional conclusions about the industrial accident process. It was also intended to seek out the right direction for countermeasures by examining unsafe acts comprehensively rather than limiting the analysis to human errors only. In an analysis of 150 industrial accident cases that caused fatalities and featured relatively clear accident scenarios, the results showed that only 36.0% (54 cases) of the workers recognized the situation they confronted as risky, out of which 29.6% (16 cases) thought of the risk as trivial. In addition, even when the risks were recognized, most workers attempted to solve the hazardous situations in ways that violated rules or regulations. If analyzed with a focus on human errors, accidents can be attributed to personal deviations. However, if considered with an emphasis on safety rules or regulations, the focus will naturally move to the question of whether the workers intentionally violated them or not. As a consequence, failure of managerial efforts may be highlighted. Therefore, it was concluded that management should consider unsafe acts comprehensively, with violations included in principle, during accident investigations and the development of countermeasures to prevent future accidents.
Journal of Korean Society of Industrial and Systems Engineering
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v.35
no.2
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pp.21-29
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2012
Person characteristics and the perception of organization climate affect on the performances associated with causes of job stress, and may induce various types of human errors. For incidence, a person's adaptation to organizational traits can influence on a person's performance with tasks assigned as well as job satisfaction, a change of occupation, etc. There are several evaluation methods such as an aptitude test to evaluate the suitability of department allocation. However, only person's traits such as an aptitude has been associated with department allocation and job assignment for the personnel management. This paper shows not only an evaluation result on the job-stress of the workers in nuclear power plants (NPPs), but also the relationships between the job-stress and the coincidences of group-personal, team-personal traits. Then, we systematically deduct a basic information on the factors to be considered to manage the organizational traits and job stress. We expect this result can contribute to enhance the organizational management against to the human errors as well as for the promotion of safety and efficiency of NPPs.
It is well known that urgency resulted from time stress can be a great cause to industrial accidents. Therefore, time stress has been studied in the aspect of macroscopic view, namely industrial safety management, but has not been studied in microscopic view such as psychophysiological approach. Among diverse psychophysiological indices, Electroencephalogram(EEG) would be on of the most objective psychophysiological research technique on human errors though few research has been taken yet. This study aimed to get characteristics of human error while committing a simple arithmetic addition task by utilizing the power spectrum technique of EEG data. Each experiment was composed of 2 tasks under different condition - with and without time stress. As subjects, 5 young undergraduate students in their early twenties participated in this study. The results advocated a well-known fact that time stress downgrades the performance of human workers. However, correct answer rate and response time were not significantly influenced by time stress factor which might be explained by the constructural factor adopted in the present study. As in the previous studies, among various EEG-related measures, relative band power ratios of ${\alpha}$ and ${\beta}$ waves to sum of ${\alpha}$,${\beta}$,${\theta}$ wave powers, namely $P_{{\alpha}/({\alpha}+{\beta}+{\theta})}$ and $P_{{\beta}/({\alpha}+{\beta}+{\theta})}$ seemed to be the most effective measures to grasp variation of brain activities in time-stressed situation so that discussions were expanded about their variations.
It is reported that about 20% of accidents at nuclear power plants in Korea and abroad are caused by human error. One of the main factors contributing to human error is fatigue, so it is necessary to prevent human errors that may occur when the task is performed in an improper state by grasping the status of the operator in advance. In this study, we propose a method of evaluating operator's fitness-for-duty (FFD) using various parameters including eye movement data, subjective fatigue ratings, and operator's performance. Parameters for evaluating FFD were selected through a literature survey. We performed experiments that test subjects who felt various levels of fatigue monitor information of indicators and diagnose a system malfunction. In order to find meaningful characteristics in measured data consisting of various parameters, hierarchical clustering analysis, an unsupervised machine-learning technique, is used. The characteristics of each cluster were analyzed; fitness-for-duty of each cluster was evaluated. The appropriateness of the number of clusters obtained through clustering analysis was evaluated using both the Elbow and Silhouette methods. Finally, it was statistically shown that the suggested methodology for evaluating FFD does not generate additional fatigue in subjects. Relevance to industry: The methodology for evaluating an operator's fitness for duty in advance is proposed, and it can prevent human errors that might be caused by inappropriate condition in nuclear industries.
Journal of the Korean Society of Manufacturing Process Engineers
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v.19
no.10
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pp.68-73
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2020
The proportion of airline accidents caused by human factors is steadily increasing. The aviation industry has made considerable progress in reducing the accident rate; however, since the early 1980s, the accident rate has remained constant. Due to airspace congestion, the safety margins of these existing safety promotion methods are gradually decreasing; thus, new methods to prevent accidents and quasi-accidents must be devised. Causative factors of aviation accidents include increased air traffic due to increased air demand, increased cumulative working hours due to long-distance flights, and complicated flight environments. Accidents often occur when several small errors accumulate in the normal course of operation, rather than after a single error. Accordingly, in this study, the impacts on air navigation due to human error by aviation maintenance personnel and varying international standards (i.e., KOCA vs. F.A.A vs. EASA) analyzed, and the relationship between human decision-making and behavior was investigated. The resulting safety analysis and alternatives were presented to prevent aviation maintenance accidents and cognitive ergonomics errors.
Journal of The Korean Association For Science Education
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v.22
no.3
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pp.455-465
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2002
This study investigates students' preconceptions about measurement theory; repeating measurements. how to handle repeat measurements, measurement errors, and uncertainty. Thirty students in seventh grade participated in this study. Students' conceptions were elicited using observation and interview notes. Half of the students measured only two times. and none of them more than five times. After repeating measurements, seventy seven percent of them selected result according to their feelings, while only thirteen percent of them calculated the mean. Sixty percent of them regarded the main cause of measurement errors as their mistakes, not as the problems of environment or measuring instrument. Most students thought the main reason of various results by different persons or time period as human. Forty percent of them denied the uncertainty of measurement, while thirty three agreed, and most students thought the reason of uncertainty was due to human imperfection. This study showed more than half of the students did not know how to handle repeat measurements, and they regarded the cause of measurement errors as their mistakes. In addition, they thought the main reason of various measuring results and uncertainty as human.
This study is a narrative review introducing global trends in patient safety education within medical schools and exploring the status of Korean education. Core competences for patient safety include patient centeredness, teamwork, evidence- and information-based practice, quality improvement, addressing medical errors, managing human factors and system complexity, and patient safety knowledge and responsibility. According to a Korean report addressing the role of doctors, patient safety was described as a subcategory of clinical care. Doctors' roles in patient safety included taking precautions, educating patients about the side effects of drugs, and implementing rapid treatment and appropriate follow-up when patient safety is compromised. The Korean Association of Medical Colleges suggested patient safety competence as one of eight essential human and society-centered learning outcomes. They included appropriate attitude and knowledge, human factors, a systematic approach, teamwork skills, engaging with patients and carers, and dealing with common errors. Four Korean medical schools reported integration of a patient safety course in their preclinical curriculum. Studies have shown that students experience difficulty in reporting medical errors because of hierarchical culture. It seems that patient safety is considered in a narrow sense and its education is limited in Korea. Patient safety is not a topic for dealing with only adverse events, but a science to prevent and detect early system failure. Patient safety emphasizes patient perspectives, so it has a different paradigm of medical ethics and professionalism, which have doctor-centered perspectives. Medical educators in Korea should understand patient safety concepts to implement patient safety curriculum. Further research should be done on communication in hierarchical culture and patient safety education during clerkship.
Objective: This paper discusses the recent challenges to human factors engineering due to the safety culture. Background: As incidents occurring in specific fields such as logistics, plant, energy and medical sectors in Korea, as well as in the public sectors including railway, road, aviation and shipping, are recently raised as social issues from the disaster dimension, those incidents are dealt with as man-made disasters in many cases. The trend regarding all accidents as man-made disasters has been expanded in the active perspective that the controllability of all incidents should be ensured in technology development, due to change from a fatal point of view regarding disasters as random occurrence of uncertainties in the past. Method: Man-made disasters are concluded as human errors, and safety culture stands out as a cause of human errors or a new cause item recently. Because safety culture, however, is a very comprehensive term, of which true nature is obscure, although many definitions of safety culture have been presented, the safety culture may make avoid the true nature and responsibility of an incident, or make the main player and subject obscure. Raising safety culture as a cause without presenting a specific countermeasure will be just a wisdom of hindsight. Results and Conclusion: This study reviews the fundamental discussions on "Is safety culture a task of human factors engineering?" and the existing approach carried out from various perspectives in order to seek an effective approach on the new task of safety culture in the human factors engineering field. This study discusses an engineering approach to meet a precondition that safety culture is not just an added factor through a review of the approaches in the proactive fields such as nuclear power and aviation, and the traditional approaches of human factors engineering. Application: This study especially defines the perspective of socio-technological system that has expanded the existing man-machine system, and discusses a systemic approach embracing various interactions, and several overriding tasks.
The application of advanced Main Control Room(MCR) is accompanied with lots of changes and different forms and features through the virtue of new digital technologies. The characteristics of these digital technologies and devices give many opportunities to the interface management, and can be integrated into a compact single workstation in advanced MCR so that workers can operate the plant with minimum physical burden under any operation conditions. However, these devices may introduce new types of human errors and thus a means to evaluate and prevent such errors is needed, especially those related to characteristics of digital devices. This paper reviewed the new type of human error hazards of tasks based on digital devices and surveyed researches on physiological assessment related to human error. An experiment was performed to verify human error hazards by physiological responses such as EEG which was measured to evaluate the cognitive workload of operators. And also, the performances of four tasks which are representative in human error hazard tasks based on digital devices were compared. Response time, ${\beta}$ power spectrum rate of each task by EEG, and mental workload by NASA-TLX were evaluated. In the results of the experiment, the rate of the ${\beta}$ power was increased in the task 1 and task 4 which are searching and navigating task and memory task of hierarchical information, respectively. In case of the mental workload, in most of evaluation items, task 1 and 4 were highly rated comparatively. In this paper, human error hazards might be identified by highly cognitive workload. Conclusively, it was concluded that the predictive method which is utilized in this paper and an experimental verification can be used to ensure the safety when applying the digital devices in Nuclear Power Plants (NPPs).
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