Combining task analysis and fault tree analysis for accident and incident analysis: a case study from Bulgaria.
Combining task analysis and fault tree analysis for accident and incident analysis: a case study from Bulgaria.
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DOI：
10.1016/j.aap.2008.07.014
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发表时间：
2009-11
期刊：
影响因子：
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通讯作者：
D. Doytchev;G. Szwillus
中科院分区：
文献类型：
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作者：
D. Doytchev;G. Szwillus
了解事件和事故发生的原因对于组织的安全非常重要。为了实现这一目标，人们开发了不同的方法。为了更好地理解事件发生时的人类行为，我们提出了结合故障树分析（FTA）和任务分析（TA）的分析概念。前一种方法确定事故/事件的根本原因，而后者分析人们在工作环境中执行任务的方式以及他们如何与机器或同事互动。这些方法通过使用系统工具中的人为错误识别 (HEIST) 方法和绩效塑造因素 (PSF) 的概念进行补充，以加深对操作员行为的错误模式的洞察。 HEIST 显示了导致人为错误的外部错误模式以及促使人为错误的因素。为了证明该方法的有效性，对保加利亚水力发电厂进行了案例研究。结合上述方法对工厂地下室进水事件进行了分析。案例研究表明，任务分析与其他方法相结合可以成功地应用于人为错误分析，揭示现实情况下错误行为的细节。
Understanding the reasons for incident and accident occurrence is important for an organization’s safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. 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 insight into the error modes of an operator’s behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. 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 analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation.