Journal of Health and Safety at Work

---

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.

.

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.

.

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.

.

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.

---

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.

---

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.

---

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.

---

Introduction: Labor is one of the most important wards of hospital, where human error is high. Midwifery errors in the maternity ward and in the delivery can be a serious threat to the health of the mother and the infant, resulting in increased treatment costs. Factors affecting human error are diversity in work, high workload, and fatigue. Therefore, this study aimed to evaluate the midwifery errors in the maternity ward using the systematic human error reduction and prediction approach (SHERPA) technique.
Material and Methods: This cross-sectional study was conducted in 2019, during which different midwifery tasks were determined in four stages of admitting, pre-labor, delivery, and postpartum. Tasks and sub-tasks were identified using the hierarchical task analysis (HTA) technique and human error was evaluated using the SHERPA technique.
Results: The results of the HTA technique identified 19 main tasks, 52 sub-tasks, and 114 activities. After assessing human error risk with the SHERPA technique, the performance was the most frequent type of  error and the highest frequency was related to the undesirable risk level.
Conclusion: The errors of the midwifery profession in the hospital’s labor are high-risk and largely critical. Factors such as high workload, time pressure, and fatigue influence the incidence of human error. In order to reduce human error in this area, strategies such as reducing staff workload, developing standard checklists and guidelines are essential to reduce human error in this ward.