A Index terms Links Index

(1)

Index terms Links

A

Accident causation analysis. See also Root cause analysis system (RCAS)

data collection systems and 255 261 262

human error concept of 41

onion model of 262

Accountability, design process implementation guidelines 347

Action oriented techniques 162

decision/action flow diagram 169

hierarchical task analysis (HTA) 162

operational sequence diagram (OSD) 172

operator action event tree (OAET) 167

signal-flow graph analysis 176

Active human error

accident causation analysis 41

defined xvii 43

Activity analysis, error prediction and reduction, data acquisition

techniques 157

Age, performance-influencing factors 141

Alarms, control panel design 123

Allocation of function, human factors engineering/ergonomics 63 Anonymity, data collection systems, cultural factors 259 Atmospheric conditions, performance-influencing factors 112 Audit techniques

MANAGER, sociotechnical systems 90 93

offshore emergency blowdown operations, case study 334

(2)

Audit techniques (Continued)

system-induced error approach, performance optimization 21

traditional safety engineering 54

Authority, performance-influencing factors 145 Automation

human factors engineering/ergonomics 63

offshore emergency blowdown operations, audit, case study 340 342

B

Behavior modification, traditional safety engineering 48

Black box model 67 68

Blame and punishment

corporate culture and 249 253

design process implementation guidelines 347 356

C

Case studies 291

approach of 17 22

hydrocarbon leak from pipe 292

offshore emergency blowdown operations, audit 334

overview 291

solvent mischarge in batch plant

described 307

standard operating procedure design for 314

visual display unit design 325

Causation. See Accident causation analysis; Root cause analysis system (RCAS)

Change analysis, root cause analysis system, data collection 284 Checks, performance-influencing factors, task characteristics 127 Chemical process quantitative risk analysis (CPQRA)

data collection systems 253

(3)

Chemical process quantitative risk analysis (CPQRA) (Continued)

over reliance on, performance-influencing factors (PIFs) 146

task analysis, cognitive 181 186

Circadian rhythm, performance-influencing factors 116 Clarity of instruction, performance-influencing factors, task

characteristics 126 Classification of error, cognitive systems engineering 68

Cognitive systems engineering 67

applications of 78

conclusions regarding 84

error prediction 79

error reduction 79

generally 78

root cause analysis using sequential error model 81

summarized 81

classification of errors 68 74

error recovery 76

knowledge-based mistakes 76

rule-based mistakes 74

slips and mistakes 74

generic error modeling system (GEMS) 70

human error perspective of 46

overview of 67

prediction 68 skill-, rule-, and knowledge-based classification 69 71 72

stepladder model

case example 94

described 76

Cognitive task analysis techniques 179

critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183

(4)

Cognitive task analysis techniques (Continued)

overview of 179

Cognitive "tunnel vision", defined xvii Communication

offshore emergency blowdown operations, audit, case study 337

performance-influencing factors (PIFs) 142

Complexity, performance-influencing factors 110

Consciousness raising, of human error 3

Consequence analysis, risk assessment 216

Consultants, error prediction and reduction 155

Control actions, human-machine interface 62

Control panel design, performance-influencing factors 121 Corporate culture. See Cultural factors

Critical action and decision evaluation technique (CADET) 180

Critical Human Action Profile (CHAP) 282

Critical incident technique, error prediction and reduction 156 Critical task identification and screening analysis, risk assessment 209 211 Cultural factors

blame and punishment 249 253

data collection 259 289

design process implementation guidelines 356

error-inducing conditions 18

rule book culture xix 146

D

Danger, performance-influencing factors 110

Data acquisition techniques 154

See also Data collection

activity analysis 157

critical incident technique 156

documentation 157

(5)

Data acquisition techniques (Continued)

expert consultation 154

observation 156

simulators and mock-ups 158

withholding information technique 160

Data collection 247

See also Data acquisition techniques

data types 260

chemical processing industry 260

generally 260

defined 247

implementation and monitoring 287

interpretation 268

methods 266

major incident analysis 267

personnel responsible for 266

reporting form design 266

storage and retrieval 267

organizational factors 255

overview of 247

root cause analysis system 270

change analysis 284

evaluation 285

generally 270

human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274

root cause coding 275 278 279

sequentially timed events plotting procedure (STEP) 273 275

tree of causes/variation diagram 270

set-up 288

systems, generally 249

system types 251

(6)

Data collection (Continued)

generally 251 254

incident reporting systems (IRS) 252

near miss reporting system (NMRS) 252

quantitative human reliability data collection system 253

root cause analysis system (RCAS) 253

Decision/action flow diagram, described 169

Decision-making stage

human-machine interface 61

offshore emergency blowdown operations, audit, case study 338 340 Demand-resource mismatch view, of human error 15 Design factors

performance-influencing factors and 106 120

visual display unit design, case study 325

Disciplinary action, traditional safety engineering 53 Documentation

error prediction and reduction, data acquisition techniques 157

predictive human error analysis (PHEA) 192

E

Emergency situations, performance-influencing factors 149 Emotional control, performance-influencing factors 140

Encystment, defined xvii

Engineering. See Cognitive systems engineering; Human factors engineering/ergonomics; Process safety review procedures;

Reliability engineering; Traditional safety engineering

Equipment design, performance-influencing factors 120

Ergonomics checklists 196

See also Human factors engineering/ergonomics (HFE/E)

application of 196

(7)

Ergonomics checklists (Continued)

examples of 196

Error. See Human error

Error-inducing conditions/ described 18

Error prediction and reduction 153

See also Predictive human error analysis (PHEA)

cognitive systems engineering 68 79 81

83

data acquisition techniques 154

activity analysis 157

critical incident technique 156

documentation 157

expert consultation 154

observation 156

simulators and mock-ups 158

withholding information technique 160

ergonomics checklists 196

human error analysis techniques 189

overview of 189

predictive 190

work analysis 194

overview of 153

program benefits 10

risk assessment and 201

See also Risk assessment

system-induced error approach, performance optimization 20 21

task analysis 161

action oriented techniques 162

applications of 161

cognitive techniques 179

evaluation of 187

(8)

Error prediction and reduction (Continued)

purpose of 161

Error recovery, cognitive systems engineering 76 Events and Causal Factors Charting (ECFC) 282

Event tree, THERP case study 229

Experience, performance-influencing factors 133 Expert consultation, error prediction and reduction 154

External error mode, defined xvii

Externals, defined xvii

F

Failure model, risk assessment, quantification process 225 Failure modes effects and criticality analysis (FMECA)

over reliance on, management policies 146

performance-influencing factors and 109

False assumptions, case study illustrating 27 Fatigue, performance-influencing factors 115 Fault diagnostic support, performance-influencing factors 128 Fault tree construction

human reliability role 202

representation 219 Feedback

cognitive systems engineering, stepladder model 76

human error 8

G

Generic error modeling system (GEMS) 70

Goals, design process implementation guidelines 347 Groups, performance-influencing factors 145

(9)

H

Hazard and operability (HAZOP) study

hazard identification by 19

over reliance on, performance-influencing factors (PIFs) 146

risk assessment

critical task identification and screening analysis 211

human reliability role 202 205 206

Hazard identification, HAZOP 19

Health & Safety Executive Research Program (U.K.) 90 Hierarchical task analysis (HTA)

case study, solvent mischarge 315

described 162

Hours of labor, performance-influencing factors 113

Human error 1

See also entries under Error

benefits of elimination program for 10

case studies of 22

concepts of 39

generally 39

reliability engineering 40

costs of 5

demand-resource mismatch view of 15

neglect of, rationale for 10

overview of 1

perspectives on 44

cognitive systems engineering 46 67

See also Cognitive systems engineering

human factors engineering/ergonomics 44 55

See also Human factors engineering/ergonomics

(10)

Human error (Continued)

sociotechnical systems 46 85

See also Sociotechnical systems

traditional safety engineering 44 47

See also Traditional safety engineering

probability, defined xvii

role of, in accidents 4

system-induced error approach

case study approach illustrating 17

overview of 12 20

practical applications 19

Human error analysis techniques 189

overview of 189

predictive 190

work analysis 194

Human factors assessment methodology (HFAM)

data collection systems and 265

Human factors engineering/ergonomics (HFE/E) 55 See also Ergonomics checklists

automation and allocation of function 63

evaluation of 67

human-machine interface

control actions 62

decision-making stage 61

generally 56

perception stage 60

information processing and mental workload 62

(11)

Human factors engineering/ergonomics (HFE/E) (Continued)

overview of 55

system-induced error approach, performance optimization 19

system reliability assessment and error 65

Human information-processing

defined xvii

Human-machine interface

defined xvii

ergonomics checklists 197

control actions 62

decision-making stage 61

generally 56

perception stage 60

inadequate, case study illustrating 24

Human performance evaluation system (HPES)

cultural factors 259

personnel responsible 266

Human performance investigation process (HPIP) 278 282 Human reliability

assessment methodology for, SPEAR 207 210

defined xvii

Hydrocarbon leak, case study 292

I

Identifications, inadequate, case study illustrating 27

Implementation, data collection system 287

Implementation guidelines 345

design process 346

accountability, objectives, and goals 347

(12)

Implementation guidelines (Continued)

change management 352

generally 346

incident investigations 356

process and equipment integrity 353

process safety review procedures 348

risk management 351

training and performance 354

overview 345

set-up 357

Incident reporting systems (IRS), described 252 Influence diagram approach (risk assessment)

calculations for 241

quantification techniques 238

Influence modeling and assessment systems (IMAS), described 183 Information processing, human factors engineering/ergonomics 62 Inspection, design process implementation guidelines 353 Instruction, clarity of, performance-influencing factors 126

See also Training

Instrumentation scales, inappropriate, case study illustrating 27 Interface. See Human-machine interface

Internal error mechanism, defined xviii

Internal error mode, defined xviii

Internals, defined xviii

International Safety Rating System (ISRS) 54 Investigation management

data collection types 262

(13)

J

Job aids and procedures, performance-influencing factors 123

K

Knowledge-based classification. See Skill-, rule-, and knowledge-based classification (SRK)

Knowledge-based level of control, defined xviii Knowledge-based tasks

cognitive systems engineering, classification of errors 76 visual display unit design, case studies 328 332

L

Labeling

equipment design, performance-influencing factors 120

inadequate, case study illustrating 26

Latent human error

accident causation analysis 41 42

data collection and 257

defined xviii 43

Leadership, performance-influencing factors 145 See also Management policies

Lighting, performance-influencing factors, operating environment 111 Locus of control

defined xviii

performance-influencing factors (PIFs), personality factors 140

M

Maintenance, design process implementation guidelines 353 Major incident analysis, data collection methods 267

(14)

Management Oversight and Risk Tree (MORT), root cause analysis

system, data collection 273 274 278

284 Management policies

implementation guidelines, set-up 358

performance-influencing factors (PIFs), organizational and social

factors 145 root cause analysis system, data collection 286

MANAGER

performance-influencing factors 105

Manual variability, defined xviii

Mental model, human factors engineering/ergonomics 61 64 Mental workload, human factors engineering/ergonomics 62 Mindset syndrome

cognitive systems engineering 76

defined xviii

Mistakes

defined xviii

Mock-ups, error prediction and reduction 158 Monitoring

data collection system 287

human factors engineering/ergonomics, automation 64 Motivation, performance-influencing factors 136

N

Near miss reporting system (NMRS)

(15)

Near miss reporting system (NMRS) (Continued)

described 252

Night work, performance-influencing factors 116

Noise, performance-influencing factors 111

O

Objectives, design process implementation guidelines 347 Observation, error prediction and reduction 156 Offshore emergency blowdown operations, case studies 334 Operating environment, performance-influencing factors 109 Operating procedures, flawed, case study illustrating 30 Operational sequence diagram (OSD), described 172 Operator action event tree (OAET), de-scribed 167

Operator characteristics 133

experience 133

personality factors 135

physical condition and age 141

Organizational factors data collection

chemical processing industry 265

generally 255

failures, case study illustrating 35

human error and 5

ineffective, case study illustrating 32

performance-influencing factors (PIFs) 142

system-induced error approach and 22

Organizational learning, performance-influencing factors 147

(16)

P

Partitioned operational sequence diagram (OSD), described 175 Perception stage, human-machine interface 60

Performance-influencing factors (PIFs) 103

applications of 105

classification structures for 107

data collection systems and 264

defined xviii

interactions of factors in 148

operating environment 109

chemical process environment 109

physical work environment 111

work pattern 112

operator characteristics 133

experience 133

personality factors 135

physical condition and age 141

organizational and social factors 142

teamwork and communication 142

overview of 103

risk assessment

qualitative human error analysis 212

success likelihood index method (SLIM) 234

task characteristics 120

control panel design 121

equipment design 120

job aids and procedures 123

training 128

variability of performance, normal and emergency situations 149 Performance optimization, system-induced error approach 19

(17)

Performance-shaping factors (PSFs) 103 See also Performance-influencing factors (PIFs)

Personality, performance-influencing factors 135 Personal protective equipment (PPE)

safety campaigns, traditional safety engineering 51 Physical condition and age, performance-influencing factors 141 Physical work environment, performance-influencing factors 111 Plant investigation, human performance investigation process (HPIP) 282 Policy factors, error-inducing conditions 18

See also Management policies

Population stereotype, defined xviii

Prediction. See Error prediction and reduction Predictive human error analysis (PHEA)

case study, solvent mischarge 319 321

described 190

risk assessment

qualitative analysis methods 218 219

Prevention. See Error prediction and reduction

Probabilistic safety analysis (PSA) 104

Problem solving, implementation guidelines 346 Procedures, performance-influencing factors 123 Process safety review procedures, design process implementation

guidelines 348 Production requirements, safety requirements versus 129

Protocol analysis, expert consultation 155

Psychology

personality, performance-influencing factors 135

root cause analysis system 286

Punishment. See Blame and punishment

(18)

Q

Qualitative human error analysis 211

case study, in SPEAR 217

consequence analysis 216

error reduction analysis 217

overview of 211

performance influencing factor analysis 212

predictive human error analysis (PHEA) 213

task analysis 212

Quality assurance, Total Quality Management (TQM) 253 Quantification, risk assessment, human reliability role in 206

See also Risk assessment: quantification

Quantitative human reliability data collection system 253

Quantitative risk assessment (QRA) 103

R

Reactance, defined xviii

Recovery analysis, predictive human error analysis 216

Recovery error, defined xviii 43

Reliability engineering, human error concept of 40 Reporting form design, data collection methods 266

Representation, risk assessment 219

Responsibility

failures in, case study illustrating 34

Rest pauses, performance-influencing factors 113

Retrieval methods, data collection 267

Risk assessment 201

critical task identification and screening analysis 209 211

defined xviii

(19)

Risk assessment (Continued)

human reliability role in 202

case study 202

error implications for 205

quantification aspects 206

implementation guidelines 346

overview of 201

case study, in SPEAR 217

consequence analysis 216

error reduction analysis 217

overview of 211

performance influencing factor analysis 212 predictive human error analysis (PHEA) 213

task analysis 212

quantification 222

human reliability role in 206

overview of 222

quantification process 224

quantification techniques 225

influence diagram approach 238 238

success likelihood index method (SLIM) 233 technique for human error rate prediction (THERP) 226

representation 219 system for predictive error analysis and reduction (SPEAR) 207 210

Risk homeostasis, defined xviii

Risk homeostasis theory (RHT), performance-influencing factors 138 Risk-taking, performance-influencing factors 137

Role ambiguity, defined xix

Role conflict, defined xix

(20)

Root cause

analysis of, using sequential error model 81

case study, hydrocarbon leak, STEP 297

defined xix

Root cause analysis system (RCAS) See also Accident causation analysis

change analysis 284

evaluation 285

generally 270

human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274

root cause coding 275 278 279

sequentially timed events plotting procedure (STEP) 273 275

tree of causes/variation diagram 270

described 253

Root cause coding 275 278 279

Routine violations, case study illustrating 30 Rule-based classification. See Skill-, rule-, and knowledge-based

classification (SRK)

Rule-based level of control, defined xix

Rule-based tasks

error classification, cognitive systems engineering 74

visual display unit design, case studies 326 328 330 Rule book culture

defined xix

Rules and procedures, performance-influencing factors 123

(21)

S

Safety campaigns, traditional safety engineering 50 Safety management system audits, traditional safety engineering 54 Safety requirements, production requirements versus 129 Scheduling, performance-influencing factors 116 Sequential error model. See Skill-, rule-, knowledge-based

classification (SRK)

Sequential Timed Event Plotting (STEP)

case study, hydrocarbon leak 292

data collection system and 264

design process implementation strategies 357

root cause analysis system 273 275

Shift rotation, performance-influencing factors 116

Signal-flow graph analysis, described 176

Simulators and mock-ups, error prediction and reduction 158 Skill(s)

deterioration of, human factors engineering/ergonomics 63 level of, performance-influencing factors 133 Skill-, rule-, knowledge-based classification (SRK)

case examples 96

cognitive systems engineering 69 71 72

root cause analysis using 81

Skill-based level of control, defined xix

Skill-based task, visual display unit design, case studies 326 329 Sleep deprivation, performance-influencing factors 113 Slips

defined xix

Social factors, performance-influencing factors 142 Sociotechnical approach to human reliability (STAHR). See Influence

diagram approach (IDA)

(22)

Sociotechnical systems 85

comparisons among approaches of 93

human factors analysis methodology 87

overview of 85

TRIPOD approach 86

U.K. Health & Safety Executive Research Program 90 Solvent mischarge, in batch plant, case studies 307 Spatial operational sequence diagram (OSD), described 176 Standard operating procedures (SOPs), solvent mischarge in batch

plant, case studies 314

Stepladder model

case example 94

described 76

Stereotype fixation, defined xix

Stereotype takeover, defined xix

Stimulus operation response team (SORTM) 282

Storage methods, data collection 267

Stress

case study illustrating 23

performance-influencing factors

emergency situations 149

operator characteristics 134

risk assessment 235

Success likelihood index method (SLIM) 233

Suddenness of onset, performance-influencing factors 110 System factors. See Organizational factors

System for predictive error analysis and reduction (SPEAR)

described 207 210

qualitative human error analysis and 211

(23)

System for predictive error analysis and reduction (SPEAR) (Continued) system-induced error approach, performance optimization 20 System-induced error approach

case study approach illustrating 17

overview of 12 20

practical applications 19

System reliability assessment, human factors engineering/ergonomics 65

T

Task analysis 161

action oriented techniques 162

decision/action flow diagram 169

hierarchical task analysis (HTA) 162

operational sequence diagram (OSD) 172

operator action event tree (OAET) 167

signal-flow graph analysis 176

applications of 161

cognitive techniques 179

critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183

overview of 179

evaluation of 187

offshore emergency blowdown operations, audit, case studies 340

purpose of 161

risk assessment, qualitative human error analysis 212 Task characteristics, performance-influencing factors 120 Task modeling, risk assessment, quantification process 224 Teamwork, performance-influencing factors 142 Technique for Human Error Rate Prediction (THERP)

case study 229

(24)

Technique for Human Error Rate Prediction (THERP) (Continued)

described 226

representation, risk assessment 219

Technology, human factors engineering/ergonomics, over reliance on 65 Temporal operational sequence diagram (OSD) 172 Testing, design process implementation guidelines 353 Thermal conditions, performance-influencing factors 112 Time dependency, performance-influencing factors 110

Total Quality Management (TQM) 253

Traditional safety engineering 47

defined xix

disadvantages of 49

disciplinary action 53

error prevention and 48

overview of 47

safety campaigns 50

safety management system audits 54

training 55

Training

data collection set-up 289

design process implementation guidelines 354 offshore emergency blowdown operations, audit, case study 336 performance-influencing factors

clarity of 126

task characteristics 128

traditional safety engineering 55

Tree of causes/variation diagram 270

(25)

TRIPOD approach

Type A and B personality, performance-influencing factors 141

U

Unforgiving environment, described 19

United Kingdom Health & Safety Executive Research Program,

V

Vagabonding, defined xix

Variation diagram, tree of causes/variation diagram 271

Verbal protocol analysis, defined xix

Violation error

defined xix 43

Visual display unit design, case studies 325

W

Warnings, performance-influencing factors 127 Withholding information technique, error prediction and reduction 160 Work analysis, human error analysis techniques 194 Workload distribution, performance-influencing factors 143 Work pattern, performance-influencing factors 112