Human errors identification in operation of meat grinder using TAFEI technique

Task analysis for error identification: a methodology for designing error-tolerant consumer products

Dear Editor-in-ChiefNurses spend much more time dealing with patients compared with other healthcare personnel. This group has a significant role in identification of threatening complexities of patients, removing medical errors and in keeping patients safe, on the other hand, a considerable amount of human errors is committed by nurses (1). Therefore, nurses have to face with many occupational risks compared with other jobs and may suits relating to occupational negligence (1). Human errors associated with nursing duties; in particular, medication error has been identified as a central concern for the nursing profession (1). As the result of such events, patient is hurt unwantedly and staff suffers a great deal of damage. These events often result from the change of systemic specifications in duties, group, work environment, and organization (3).The present study was a cross sectional research aimed at comparing two human error identification and assessment methods, SPAR-H and CREAM, in nursing practice at a hospital in Iran. We investigated 31 duties according to job description announced by Iran Nursing Organization and professors of nursing.In the first step, we analyzed occupational duties using Hierarchical Task Analysis (HTA) method (4). Next, different tasks are executed for each sub task. After completing CREAM and SPAR-H worksheets, we first grouped the worksheets for each duty and analyzed total error probability and error risk using SPSS-16 (Chicago, IL, USA). In order to compare the two techniques based on multivariable decision making, we used analytical hierarchy process (5).The findings of demonstrated that, the estimated human error probability by SPAR-H was higher than those estimated by CREAM, but the most critical task, taking initial measures for cardiopulmonary resuscitation until the arrival of resuscitation team, was the same in both techniques. Moreover, it was determined that both techniques have similar results in identifying and assessing critical tasks with high probability of human error (Table 1). Furthermore, there was more difference between these two techniques in ranking potential errors with low probabilities; for instance, preparing bed before arrival of patient have the rank of 27 when we used SPAR-H technique 27, while its rank using CREAM technique was determined at 10 (Table 1).Based on previous studies in this field and also eliciting domain expert knowledge, seven criteria were selected for comparing two techniques with each other (6). …

The contribution of human error related to occupational accident among traditional divers

Assault vest is one of crucial products for Indonesian army infantry soldiers to support their activities in the battlefield. Despite its importance, however, the design of the assault vest of Indonesian army was not considered Ergonomics aspects. Based on the deep interview and questionnaries distributed to 30 Indonesian Army infantry soldiers, the current design was not really comfortable and limit the freedom of movement in the battlefield. Because of this, this research aims to design a modular assault vest for Indonesian army infantry that considering Ergonomics aspects. The object of this study was the 411 Infantry Batalyon / Pandawa located in Salatiga City, Central Java Province, with a total sample of 30 active infantry soldiers involve in this study. The research was conducted by using Nordic Body Map method, questionnaire, deep interview, and TAFEI (Task Analysis for Error Identification) as well as Kansei Engineering. The prototype was built to test the proposed assault vest design. A physiological test using the physiological test method of Dr. Woldemar Gerschler was conducted to test the prototype and then the results of the data (VO2) are tested by applying t-test statistical analysis to see whether the proposed assault vest design will have better performance than existing assault vest. Physiological tests were carried out by 23 respondents who were members of a football club. The test indicate that the proposed design show better result in terms of oxygen consumption.

Review of “Just culture – Balancing safety and accountability” and “The field guide to understanding human error”

Chapter 9 - Human Factors and Human Error

Using system simulation to model the impact of human error in a maritime system

According to a survey of the economically active elderly population in South Korea, most of them are employed in the service sector, with many men working as custodians. This study investigates the characteristics of injuries affecting apartment custodians, one of the representative jobs for older male workers, as well as the characteristics of accident causes based on human errors. The study used information processing as a framework to identify the cause of accidents that affected 831 male apartment custodians. This study investigated the characteristics of injured persons and features of accidents. The majority of accidents were caused by human errors, in particular perceptual (45.5%) and action (26.9%) errors. The rate of accidents caused by human errors rose from 85.3% among those aged below 60 to 91.4% among those aged 70 or above. Furthermore, the rate of accidents caused by perceptual errors was higher among those aged 60 or above (45.0%) than those aged below 60 (31.4%). The findings of this study imply that accident prevention measures must be customized to older workers according to the different employment conditions.

By introducing autonomous or software-controlled systems, human operators are increasingly required to perform cognitive-intensive tasks in addition to existing labour-intensive tasks. As a result, it will be more difficult to identify human roles in future complex systems with traditional approaches such as hierarchical task analysis used in the conventional HRA. This paper proposes a novel systematic approach for a human reliability assessment to better understand human activities in complex systems. The proposed framework is a hybrid method combining the System Theoretic Process Analysis (STPA) and the Success Likelihood Index Method (SLIM) to assess the system reliability. The STPA is adopted to analyse the interaction relationship between different system components. The primary purpose of STPA is to find and analyse human activities that affect the risk in human-machine interaction systems. Then the identified human activities are evaluated and quantified by the SLIM as a probability of human error. The system reliability block diagram represents the derived human error probabilities to assess the entire system for a probabilistic risk assessment. Furthermore, the study proposed system alternations by comparing three different system configurations. Results demonstrate the importance of human performance in a complex system where humans, machines, and software interact.

Accidents provide important learning points to prevent future mishaps. In its approach to accident prevention one technique that Shell uses is the Tripod accident analysis tree.In the past there has been a tendency in all organisations to blame accidents on the people who suffer them and to see unsafe acts as arising from the stupidity, carelessness or recklessness of particular individuals. Accident investigations frequently cite 'human error' as the cause and many people still see such errors as the beginning and end of the accident sequence. The three more tangible components of such accident investigations are unsafe acts, failures of defences and the accidents themselves. Such unsafe acts or 'active failures' are often seen as the most important part of the accident story. In reality the story has its beginnings much earlier in areas such as Design, Procedures, Training or Maintenance Management, areas known as 'latent failures',To better understand the underlying causes of accidents, in 1988 Shell commissioned a behavioural research program called Tripod. Tripod does not address unsafe acts and hazards directly, but places them in context in a model of an accident which seeks to define the underlying organisational factors that provoke unsafe acts, and that allow errors to turn into accidents. The research has established that latent failures may be categorised into a small number of disruptive processes. These latent failures are incorporated into an accident diagram in the form of a 'tree', and improve our understanding of the causes of accidents, and direct our recommendations for improvement into areas that are likely to be the most effective.

Introduction: In examining the unfortunate events that have taken place in the industrial and health sectors, human error is considered as the main cause of these events. Given the sensitivity and importance of medical careers, the occurrence of errors can lead to irreparable consequences. The purpose of this study was to investigate the human error in the emergency department of Imam Khomeini Hospital in Jiroft.
 Methods: This study was a cross-sectional and descriptive one. Emergency nurses' job duties have been analyzed by interviewing emergency nurses and studying nursing job guidelines and procedures using hierarchical task analysis. Finally, using the Systematic Human Error Reduction and Prediction Approach, human errors in nursing care were analyzed.
 Results: Generally, 4 tasks, 18 sub-tasks and 91 types of errors related to nursing activities were identified. Number of errors found, 27 (30%) Action errors, 18 (20%) Checking errors, 19 (21%) Retrieval errors, 12 (13%) communication errors, and 15 (16%) selection errors Were. As can be seen, the largest number of errors was related to the type of Action errors.
 Conclusion: Considering the results of the present study, the highest numbers of errors were related to Action and Checking errors respectively, which due to the sensitivity of nursing jobs and especially in the emergency department, require the use of highly skilled people to perform tasks that require high concentration and accuracy.

It is well known that human error is the key contributor in most marine accidents. Nevertheless, human error is not the cause of accidents or mishaps in the new view on human errors; it is the deeper trouble of the MMEM (Man-Machine-Environment-Management) system. The key point for human error analysis is to find out the connection between human error and the features of system elements, that is the contexts of human error (Operating environment, Organization influence, etc). For this reason, this paper shows an approach for mining the human factors data which influence the occurrence of human error. This approach bases on the data collected on HFACS (Human Factor Analysis and Classification System) Model. It can be used for analysis of human factors and risk management of marine industry.

As a high-tech industry, civil aviation industry should focus on technology, but accident reports show that at least 3/4 of the accidents are caused by human error. Therefore, in ATM system, human error is a potential weak link. We must take measures to minimize human error and its impact, and optimize the quality of human operation for error detection and recovery. The ultimate goal of the research on human errors in air traffic control is to take protective measures and means against human unsafe behaviors, so the identification and analysis of human errors in air traffic control is very important.KeywordsAir traffic controlHuman errorKnowledge representation frameworkOntologyRule reasoning

Combining task analysis and fault tree analysis for accident and incident analysis: A case study from Bulgaria

Background: Electricity is considered as the fifth cause of occupational deaths. Occupational accidents caused by electricity do not form a high percentage of total occupational accidents, but are considered due to the severity of injuries which often result in death. The present study aimed to investigate the factors affecting occupational accidents among employees of a power distribution company in Khuzestan province. Methods: The present study was a descriptive-analytical study which conducted as cross-sectional on the files related to the accidents of the personnel of a company in 2017. Inclusion criteria were a history of accidents during the last 5 years from 2013 to 2017. Thus, all the personnel files of the employees of the company were reviewed and a number of 92 files of the personnel who were injured during the above-mentioned years were extracted. The required information such as demographic information (age, marital status, education level), organizational information of the injured person (employment status, job title), type of injury and place of injury on the body, rate of accidents in different seasons, days, and hours were recorded on a specific worksheet in the files. SPSS software version 22 was used for analyzing the factors affecting occupational accidents using descriptive tests and chi-square test. Significance level was considered as 0.05. Results:The maximum number of accidents occurred in summer during 8 to 10 am and the age group of 25 to 29 years reported the highest number of fatalities. In addition, most accidents occurred in the occupational group having a job experience of 1 to 5 years. Conclusion: Human errors and non- use of personal protective equipment, deficit of equipment and supervision, as well as the failure in implementing technical and safety instructions were the most critical causes of accidents and the actions such as technical and safety training before starting the work were evaluated as effective measures in controlling accidents.