Journal of Health and Safety at Work

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Introduction: Emergency situation is one of the influencing factors on human error. The aim of this research was purpose to evaluate human error in emergency situation of fire and explosion at the oil company warehouse in Hamadan city applying human error probability index (HEPI).

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Material and Method: First, the scenario of emergency situation of those situation of fire and explosion at the oil company warehouse was designed and then maneuver against, was performed. The scaled questionnaire of muster for the maneuver was completed in the next stage. Collected data were analyzed to calculate the probability success for the 18 actions required in an emergency situation from starting point of the muster until the latest action to temporary sheltersafe.

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Result: The result showed that the highest probability of error occurrence was related to make safe workplace (evaluation phase) with 32.4 % and lowest probability of occurrence error in detection alarm (awareness phase) with 1.8 %, probability. The highest severity of error was in the evaluation phase and the lowest severity of error was in the awareness and recovery phase. Maximum risk level was related to the evaluating exit routes and selecting one route and choosy another exit route and minimum risk level was related to the four evaluation phases.

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Conclusion: To reduce the risk of reaction in the exit phases of an emergency situation, the following actions are recommended, based on the finding in this study: A periodic evaluation of the exit phase and modifying them if necessary, conducting more maneuvers and analyzing this results along with a sufficient feedback to the employees.

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Introduction: The human factor played major role in the accident causation. Statistics show that human error and human mistake are the primary cause for more than 80 percent of the accidents in petrochemical industry.The aim of this study wasidentification and assessment of human error due to unsuitable design which causeaccident and damage to the equipment in thesour water and SRP unit of arefinery plant.

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Material and Method: This research was qualitative case study to identify and assessment of human errors of worker in the control room of sour water within a oil refinery plant. The group of tasks with potential to causing accidents wereidentifiedby direct observation of activities and documents and individual interview. Hierarchical Task Analysis method (HTA) was used tojob analyze and the results were presented in HTA charts. All possible human errors in work stages were identified and assessed using SHERPA method.Action Errors, Checking Errors, Retrieval Errors, Communication Errors, Selection Errors were analyzed and their related data were entered in SHERPA work sheet.

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Result: The findings showed that from all of the 118 identified errors 50% were Retrieval, 22/22% wereAction Error22/22% Communication and 5.55% Selection Error.

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Conclusion: To prevent and control occurring each of the identified errors and to limit the consequences of them, appropriate counter measures such as proper control measures in the form of changes in design, including install the appropriate colored tag, digital indicator and warning lights which must be used base on the kind of system consequently, of this study showed that SHEPA can be an efficientmethod to study humanness in operational site.

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Introduction: Although risk assessment and accident prevention program have been widely used in industries such as steel industry, there are still numerous accidents in these industries. Hence, applying an accident analysis method can identify the root causes and casual factors of accidents and causal factors. Human Factors Analysis and Classification System can identify human errors in the steel industry by using an analysis of past events. The aim of this study was to identify the human errors in the steel industry using the HFACS methodology.

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Material and Method: In this study first, incident reports of industries with high risk, such as Ahvaz steel and pipe industries existing in the department of work and social security was gathered. Then, an analysis of accident was done based on HFACS model. This model has 4 levels and 18 categories which are 1 - unsafe acts of operators (that includes four subtypes) 2 - pre-conditions for unsafe acts (with seven categories) 3 - unsafe supervision (includes four categories) and 4 - the effect of association (with three categories).

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Result: In this study, 158 reports of accident in Ahvaz steel industry were analyzed by HFACS technique. This analysis showed that most of the human errors were: in the first level was related to the skill-based errors, in the second to the physical environment, in the third level to the inadequate supervision and in the fourth level to the management of resources.

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Conclusion: Studying and analyzing of past events using the HFACS technique can identify the major and root causes of accidents and can be effective on prevent repetitions of such mishaps. Also, it can be used as a basis for developing strategies to prevent future events in steel industries.

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Introduction: Biorhythm is one of the newest subject in the field of cognition of mental ergonomics which can be very effective in reduction of work-related accidents or mistakes with no apparent reason.
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Material and Method: This research is a cross-sectional, retrospective, practical and analytical-descriptive study. Delijan cement production company during 2010-2011. Census method was applied and totally 79 accidents (total of the accidents) were investigated. The required information was collected from available documents in HSE unit of the company biorhythm charts were drawn based on a dates of accidents and participants birthdays, using Natural Biorhythm Software V3.02. Human errors were classified according to reason model and were analyzed by SPSS-W software.
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Result: The results of analysis showed that 40% of accidents have been accrued in usual days and the other 60% in critical days of biorhythm cycle. Regarding errors leading to accidents, it was observed that 95% of accidents were related to human error and 5% related to equipment errors. Moreover, 65.8% of the human errors were associated with the slipping which happens during performing a task, according to reason model.
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Conclusion: Findings of this research showed that bad and critical days of individuals’ biorhythms cycle influence the occurrence of accidents. Therefore, by training and increasing the knowledge of workers regarding biological cycle and its effects on mental, emotional and physical status, each person effects can make some changes to theire work plans during days that they do not feel well, physically or mentally, in order to prevent the likely accidents.

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Introduction: Human error is considered as a crucial challenge in occupational settings. Health care system is amongst occupational environments with high rate of human errors. Numerous preceding studies noted that more than 2/3 of medical errors are preventable. Accordingly, different methods are suggested to evaluate human errors, especially in nuclear industries. The aim of this study was to evaluate the application and accuracy of HEART technique in medical health system.

Material and Method:  This qualitative study was conducted in surgical intensive care units of a hospital in Shiraz city. All nurses recorded errors were categorized regarding the given tasks and then all tasks were ranked based on the number of errors. The probability of nurses’ tasks error was estimated through AHP-HEART method and the resultant ranking was compared with the recorded errors. Additionally, the prioritization of contributing factors to errors, determined by AHP and AHP-HEART methods, was compared employing Pearson statistical test.

Results: Based on the results, there was a concordance in the rate of nurses’ error determined by HEART method and the recorded errors. However, no significant correlation was between errors contributing factors determined by AHP and AHP-HEART methods.

Conclusion: This study suggested that although HEART technique was successful to rank the tasks considering the magnitude of error probability, but the coefficients of error producing conditions should be customized for nurses’ tasks in order to provide appropriate control measures.

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Introduction: Despite the ongoing efforts to reduce human errors in various systems, errors and unsafe behavior are the main cause of accidents in the workplace. Many studies have been conducted to identify and improve human error in recent years. The number of studies about the human error with the variety of topics has made it an overall overview difficult for researchers. Therefore, a systematic review of previous studies can be the best way to share useful findings and make a trend for the future research in the field of human error.

Material and Method: After a systematic search of valid databases, the analysis was focused on the title, publication year, journal title / Congress, city/region, the level of organization, job search, type of organization and the methods used. And articles were evaluated based encryption.

Result: Three groups of human error studies were identified. The first group studies in safety management, safety assessment, and safety planning have investigated the human error. The second group has examined the influence of individual characteristics such as behavior, cognition, and education on human error. The third group has focused on data arise from the previous accident to improve behavior and reduce human error. To make a better orientation for next studies two essential aspects included chronological analysis and thematic analysis was considered.

Conclusion: This study made an attempt to identify the gaps in the studies related to human error and afford some appropriate strategies.

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Introduction: Nowadays, human error is one of the main causes of incidents in the industry. One of the vital characteristics of modern industries is that the precise control of key parts of the process is performed by operators from central control rooms, so an error by the control room staff can be disastrous. The present study is aimed at identifying and evaluating human errors in the control room of the petrochemical industry.  
Material and Methods: This is a descriptive-analytic case study that was conducted in a control room of the petrochemical industry. In this research, firstly by using hierarchical task analysis (HTA), the tasks in the control room were identified and analyzed. Then, using the extended CREAM method, possible human errors were identified, their cognitive category was determined, and their probabilities were calculated using a new approach based on BN.
Results: The results of the study showed that the most prevalent control modes for the Boardman and the senior board man were strategic and scrambled modes with error probabilities of 0.136 and 0.171, respectively.
Conclusion: According to the results obtained in the modeling section, BN can be proposed as an approach with high processing accuracy and also high accuracy in modeling human errors and problems with high input parameters affecting the output parameter.

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Introduction: Nowadays, accidents are regarded as a main risk factor for both human and economic of countries. The triggerring cause of most accident is human error. In the healthcare setting, human errors can lead to injuries and even death of patients and damage the reputation of healthcare staff. Human errors in healthcares can occur during various activities including diagnosis of a disease, drug administration, and also during the use of various appliances. Therefore, it is of critical importance to identify these errors and assess their risks.  Accordingly, the main aim of the present study was to identify and assess human errors possible to occur during the use of the ventilator device in neonatal units of  educational hospitals of Hamedan University of Medical Sciences.  
Material and Methods: This qualitative study was conducted using PUEA technique in 2017. The required data associated with the function and operation of the ventilator were gathered by investingating documents, observing the operater while using it, and interviewing with the operator. Hierarchical task analysis (HTA) was used for determining the main tasks and subtasks performed for operating the device. The identified errors were categorized into seven groups, namely planning, functional, checking, retrieval, communication, and selection errors. The PUEA method was utilized in exploring the causes of errors, the possibility of error recovery, and associated risks.
Results: Functional error was the most prevalent one (72.7 %), whereas communication error was the least prevalent one (3.03 %).  Omission and commission were the most frequent functional error. Moreover, 42.2 percent of errors had roots in lapse and slip and 12.1 percent were of knowledge-based type. Moreover, it was impossible for 79.7 percent of errors to be recovered. About 54.53 percent of errors had severe or catastrophic consequences.
Conclusion: As the risk of accidents occurring in healthcare organizations is unacceptable, it is a necessity to identify these errors and evaluate their risks. As it is costly to replace the purchased devices with less error prone devices, human error analysis should be performed in the design phase and before purchasing the devices. Moreover, errors with an unacceptable risk should be controlled based on their probable causes.

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Background: Industrial incidents are one of the major problems of today's societies. Studies in this field show that the main and most important cause of error occurrence is human factor. Therefore, the aim of this study was to identify and evaluate the risk of human error in the activities related to the operation of electrical installations of the Tehran Province Electricity Distribution Company.
Methods: This study is a qualitative and cross-sectional research was conducted by direct observation of the activities and documents, interview. Tasks and subtasks were selected and analyzed using Hierarchical task Analysis, (HTA).The results were presented in the form of  HTA. Finally, according to the instructions of SHERPA, the relevant worksheet was completed.
Results: The analysis of SHERPA worksheets showed that a total of 3399 errors were detected for 759 tasks as 39.57% of them were action errors, 32.4% review type, 7.32% recovery type, 19.64% communication type and 1.80% were selective errors. According to the results of risk assessment, 12.47% of the errors were unacceptable risks level, 59.57% were undesirable, and 20.2% were acceptable risks but need to be revised and the rest, 7.33% acceptable with no need for revision or safe ones.
Conclusion: According to the results, the most common type of error was action errors and in order to reduce this type of errors, using necessary corrective measures such as proper selection of people for occupations, training, monitoring, using smart machines, using tag out systems and checking at the suitable time and updating the instructions would be useful and effective countermeasures.

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Introduction: Cranes are of the major causes of accidents in the construction industries. As human error mostly causes crane accidents, this study aims to investigate the human errors of tower crane operators in the construction projects using SHERPA and CREAM techniques.
Material and Method: In this research, first, all of the tasks of the tower crane operator were identified and analyzed. Then, adopting SHERPA technique, probable operator errors were identified in each task and the control modes and error probability were determined by CREAM technique. Finally, all the human errors risks were assessed and the actions for risk control were defined to control them in the acceptable level.
Result: According to the SHERPA technique, 148 errors were identified in the crane operator tasks. The human error assessment showed that monitoring the anti-collision system with the risk probability of 0.0003 has the highest control factor, while monitoring the existing guards with the risk probability of 0.056 has the lowest control factor. Also, the important tasks with high human errors were monitoring the guards with the cognitive risk probability of 0.07 and the tasks with cognitive risk probability of 0.05.
Conclusion: The findings in this study indicated that using complementary qualitative and quantitative methods can provide identification and prioritization of identified errors. This can help the organization   to allocate limited organizational resources to control unacceptable risks and increase the efficiency and effectiveness eventually.

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Introduction: The development of residential and industrial areas has led to increasing gas consumption and overcrowding in gas supply networks. Accordingly, hazards and risks caused by human errors, processing and mechanical failures in pipelines, and gas leaks are on a rise. Several techniques have been so far proposed for identifying and controlling human errors. The main purpose of this study was to compare two human error evaluation techniques, namely, Human Error Template (HET) and Systematic Human Error Reduction and Prediction Approach (SHERPA) in gas supply operations using the analytic hierarchy process (AHP) to select a suitable method.
Material and Methods: This cross-sectional descriptive study was to identify the human error modes in one of the gas supply projects operating by Kurdistan Gas Company, Kurdistan, Iran. Different tasks in gas supply operations were accordingly determined by the health, safety, and environment (HSE) unit, then the ones susceptible to human errors were selected and analyzed through task analysis technique. The next step was to weight and rank the human errors by evaluating indexes based on many variables including accuracy, sensitivity, and quantity of the errors as well as usability, time, and education analysis using the Expert Choice software (ver. 11).
Results: According to the findings of this research, the criteria were ranked based on accuracy (0.339), sensitivity (0.322), quantity of errors (0.118), usability (0.116), time (0.056), education (0.050), and analysis. The inconsistency ratio was also equal to 0.1, which meant that the subjective judgments were accepted.
Conclusion: The results also showed that the analysis of human errors, using the HET, required less training and time, while the number of the detected errors and applicability in the SHERPA was greater. Considering the weight of the criteria, their importance in determining the superior technique and the weight of each one in relation to the criteria, the contribution of that method in the relevant criterion was expressed. Calculating the final weight of the techniques revealed that SHERPA with a weight of 0.53 was more practical compared with HET with a weight of 0.46.

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Introduction: Human error can occur in many work environments, especially in control rooms. Due to the vital role of the central railway traffic control room in guiding and controlling all types of trains along the railway network, any error in this control room can lead to a catastrophic accident. This study aims to identify and assess human error in the central control room of railway traffic using the HEART technique.
Material and Methods: This descriptive cross-sectional study was performed in 2021. In this research, tasks and sub-tasks were identified using the hierarchical task analysis (HTA) method. Then, the probability of human error was assessed using the HEART technique.
Results: Based on the results of the HTA method, 67 main tasks, and 149 sub-tasks were identified. The study results on the probability of human error using the HEART technique showed that the three main tasks of the traffic expert (distribution of types of diesel, establishing the freight priority, and planning the movement of trains) had the highest probability of error. In addition, the most critical factors influencing human error were “evidence of illness among employees”, “sleep disorder”, “inexperience”, “unfamiliarity”, and “stress”.
Conclusion: The results of this study indicated that the central railway traffic control room employees are prone to errors, and if these staff make errors, irreparable accidents will occur. To reduce the probability of error of these employees, measures should be considered, such as using regular and appropriate shifts, the use of skilled and competent people, and so on.

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Introduction: Human factor analysis has been identified as the most common cause of accidents in natural gas transportation and distribution facilities. The occurrence of accidents at these systems, especially gas reduction stations located in residential and industrial areas, has had catastrophic consequences. Therefore, this study aimed at analyzing critical tasks and human error assessment using the system for predictive error analysis and reduction (SPEAR) method and providing the appropriate framework for error management in the operation and maintenance of city gate stations.
Material and Methods: This descriptive cross-sectional study was conducted using the SPEAR framework and safety critical task analysis guideline to evaluate errors in gas pressure reduction stations. First, critical tasks were screened and evaluated, followed by performing task analysis by the hierarchical task analysis and detecting performance-influencing factors (PIF). Then, human errors were predicted and assessed based on the predictive human error analysis. Finally, error management was developed at three process, equipment, and training improvement levels.
Results: In general, out of 23 operations and 164 sub-tasks, 12 critical tasks were identified based on the results. Criticality level percentages were about 67% high risk, 25% moderate, and 8% low risk. In addition, 134 errors were identified which were mostly related to action (42.53%) and checking (39.55%) errors, respectively. Eventually, communication, retrieval, and selection errors were 8.96, 5.22, and 3.74%, respectively.
Conclusion: The results revealed that action and checking errors had the highest percentages. This method can be applied to appropriate the systems approach to error reduction using the PIF assessment output. The privilege affecting factors include preparing standard operation procedures, implementing a comprehensive training program, and controlling environmental hazards.

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Introduction: The accurate evaluation of error probability and risk is important. Accordingly, this Comparative study was conducted to evaluate the risk of human error in emergency situations using SLIM and Fuzzy SLIM techniques in fierfighting tasks.
Material and Methods: This cross-sectional and descriptive-analytical study was conducted among 12, using Fuzzy SLIM and SLIM techniques. 39 sub-tasks were studied in 4 phases (Awareness, Evaluation, Egress and Recovery). Considering the advantages of the Fuzzy SLIM method, fuzzy logic was used in weighting of performance shaping factors (PSF). Excel software was used to calculate the probability of error. Also, correlation and kappa statistical tests were used for data analysis in SPSS software.
Results: The mean and standard deviation of human error probability in different sub-tasks of firefighting in SLIM and Fuzzy SLIM methods were 0.095357 ± 0.026193 and 0.06490 ± 0.051748, respectivly. In 48.7 percent of the sub-tasks, the probability category of human error and the assessed risk were the same; however, in 89.7 percent of the sub-tasks, the estimated level of risk was the same in both methods. Correlation test showed that the correlation coefficient of error probability values between the two methods was 0.32, which indicated a moderate correlation in this regard. Additionally, the results of kappa statistical test for the estimated level of risk showed that there is a high agreement between Fuzzy SLIM and SLIM (P value <0.05).
Conclusion: The results of the study indicated meaningful agreement and a moderate correlation between Fuzzy SLIM and SLIM. Therefore, due to the relatively high accuracy of Fuzzy logic methods, and also the long steps of implementing the SLIM method, the Fuzzy SLIM method can be a good alternative to this method.