(the paper was presented at European ESREL conference, Estoril, Portugal, 2006)
ABSTRACT: Understanding the reasons for incident and accident occurrence is important for an organisa-tion’s safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose a analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the in-sight into the error modes of an operator’s behaviour. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident – the flooding of the plant's basement – was ana-lysed by combining the afore-mentioned methods. With our case study we show that Task Analysis in combi-nation with other methods can be applied successfully to human error analysis, revealing details about errone-ous actions in a realistic situation.
1 INTRODUCTION
Accidents and incidents have occurred since the in-vention of the first machine and the beginning of the industrial revolution. Despite the efforts of mankind to prevent or avoid them, they continue to occur. The reasons for their happening are usually com-plex. An accident may have 10 or more events that can be counted as causes (Seton, 2006). One failure may lead to another and a chain reaction may propa-gate through barriers and time to produce an unde-sired event. The most common reasons for acci-dent/incident occurrence are failure of people, equipment, supplies, or surroundings to behave or react as expected.
Understanding why accidents/incidents occur and how to prevent them is crucial in our modern world. The works of (Hollnagel, 1998), (Johnson, 2003), (Kirwan, 1994) and (Petersen, 1996) are of excep-tional importance in this respect.
Most traditional engineering accident/incident... [continues]
ABSTRACT: Understanding the reasons for incident and accident occurrence is important for an organisa-tion’s safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose a analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the in-sight into the error modes of an operator’s behaviour. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident – the flooding of the plant's basement – was ana-lysed by combining the afore-mentioned methods. With our case study we show that Task Analysis in combi-nation with other methods can be applied successfully to human error analysis, revealing details about errone-ous actions in a realistic situation.
1 INTRODUCTION
Accidents and incidents have occurred since the in-vention of the first machine and the beginning of the industrial revolution. Despite the efforts of mankind to prevent or avoid them, they continue to occur. The reasons for their happening are usually com-plex. An accident may have 10 or more events that can be counted as causes (Seton, 2006). One failure may lead to another and a chain reaction may propa-gate through barriers and time to produce an unde-sired event. The most common reasons for acci-dent/incident occurrence are failure of people, equipment, supplies, or surroundings to behave or react as expected.
Understanding why accidents/incidents occur and how to prevent them is crucial in our modern world. The works of (Hollnagel, 1998), (Johnson, 2003), (Kirwan, 1994) and (Petersen, 1996) are of excep-tional importance in this respect.
Most traditional engineering accident/incident... [continues]
Cite This Essay
- APA
-
(2008, 06). Combining Task Analysis and Fault Tree Analysis for Accident and Incident Analysis: a Case Study from Bulgaria. StudyMode.com. Retrieved 06, 2008, from http://www.studymode.com/essays/Combining-Task-Analysis-Fault-Tree-Analysis-153407.html
- MLA
-
"Combining Task Analysis and Fault Tree Analysis for Accident and Incident Analysis: a Case Study from Bulgaria" StudyMode.com. 06 2008. 06 2008 <http://www.studymode.com/essays/Combining-Task-Analysis-Fault-Tree-Analysis-153407.html>.
- CHICAGO
-
"Combining Task Analysis and Fault Tree Analysis for Accident and Incident Analysis: a Case Study from Bulgaria." StudyMode.com. 06, 2008. Accessed 06, 2008. http://www.studymode.com/essays/Combining-Task-Analysis-Fault-Tree-Analysis-153407.html.
