HUMAN RELIABILITY ASSESSMENT APPROACHES AND THEIR USE IN

MINING
Biljana Pani
1
, Mirko Vujoevi
2
Aleksandar Milutinovi
3
1
Faculty of Orani!ational "ciences, #anic$%iljana&fon$%$ac$rs
2
Faculty of Orani!ational "ciences, vujosevic$'irko&fon$%$ac$rs
3
Faculty of (eoloy and Minin, a'ilut&'ail$co'
Abstract: Statistics on and experience with accidents and failures of complex systems whose operations
depend on human activities and behaviour show that human errors are the most frequent and the most
important cause. That is why reliability and risk analyses of complex systems need to include human
reliability assessment. For that purpose, numerous models have been developed and used in practice and
some of them are already established as recommendation or industry standards. This paper presents a
review of humans' reliability approaches based on open literature insiht. !mphasis is iven to human
reliability and risk in minin which is traditionally reconi"ed as a very risky industry.
Key words: reliability, human error, risk, ha"ard, safety, minin
1. INTRODUCTION
)u'an %e*aviour is considered to %e one of t*e 'ost i'#ortant risk factors$ )u'an relia%ility is not easily
#redicta%le since #eo#le #erfor' several different functions in 'ore different environ'ents t*an any ot*er
co'#onent of a syste'$ +n addition, t*e #ossi%ility of a relations*i# %et,een #eo#le and ot*er ele'ents of a
syste' -includin ot*er #eo#le. is very vast$ /*erefore it is not #ossi%le to eli'inate *u'an errors0 *o,ever,
it is #ossi%le to evaluate to a certain deree t*e relia%ility of #eo#le involved in e1ecutin a task ,*ic* t*ey
,ere a##ro#riately trained for and #ro#ose c*ane ,*ic* could increase t*eir relia%ility$
)u'an relia%ility is t*e #ro%a%ility of acco'#lis*in a s#ecified task successfully %y *u'ans at any re2uired
stae in syste' o#eration ,it*in a defined 'ini'u' ti'e li'it -if t*e ti'e re2uire'ent is s#ecified. -3*illon,
2445.$ +t is t*e #ro%a%ility t*at a #erson ,ill accurately #erfor' an activity re2uired %y t*e syste' ,it*in t*e
de'anded ti'e -if ti'e is a li'itin factor. and ,ill not #erfor' unnecessary activities ,*ic* could jeo#ardi!e
t*e syste' -",ain6(utt'ann, 1573.$
)u'an error is t*e failure to lead #lanned actions to desired events ,it*out t*e influence of un#redicted
events -8eason, 1554.$ /*e sa'e aut*or uses t*e ter' 9unsafe act: for descri%in errors and %reakin rules
%y individuals ,*ic* lead to *a!ardous events$ )u'an error is t*e failure to #erfor' a s#ecified task -or t*e
#erfor'ance of a for%idden action. t*at could result in disru#tion of sc*eduled o#erations or da'ae to
e2ui#'ent and #ro#erty -3*illon, 2445.$
;let! -15<=. #oints out t*at >/o %la'e *u'an error for accidents is as su#erficial and un*el#ful as to %la'e
ravity for falls>$ /*erefore, t*e task is to identify t*e #otentials for *u'an error, and su%se2uently 'anae
so as to #revent errors$ +n order to successfully 'anae errors, it is necessary to reconi!e and classify
t*e'$
2. HUMAN ERROR
)u'an errors can %e vie,ed as a %reakdo,n ,it*in an individual?s 'ental activity and it can occur in
attention, 'e'ory, retention, decision 'akin, etc$
Accordin to t*e level of conition involved %e*aviour is divided into t*ree cateories -8as'ussen, 1572.@
skillA%ased, ruleA%ased, and kno,ledeA%ased$ "killA%ased %e*aviours take #lace at an unconscious level
and are often auto'ated in nature$ 8uleA%ased %e*aviours deal ,it* t*e a##lication of learned rules, so
errors occur ,*en an individual uses t*e ,ron rule or 'isa##lies a ood rule$ ;no,ledeA%ased %e*aviours
refer to novel instances ,*ere an individual 'ust a##ly #revious kno,lede$ /*ese tasks re2uire *i* 'ental
activity ,*ic* can cause #ro%le's in unusual e'erency situations and errors occur due to a lack of trainin
or infor'ation$
)u'an errors can %e classified into t,o cateories -#ser's $anual, 1573.@ situationAcaused errors -"BCs.
and *u'anAcaused errors -)BCs.$ "BCs are errors t*at are caused #ri'arily %y factors related to t*e desin
1
of t*e ,ork situation$ )BCs are errors ,it* #ri'ary causes related to so'e *u'an c*aracteristic, suc* as
sa%otae or intentional errors$
"ater and Ale1ander -"ater6Ale1ander, 2444. cateori!ed *u'an error as errors of o'ission, co''ission,
or su%stitution$ Crrors of o'ission occur ,*en an individual fails to #erfor' a re2uired task$ Crrors of
co''ission occur ,*en t*e individual carries out an action in eit*er t*e incorrect 'anner or at t*e incorrect
ti'e$ "u%stitution errors arise ,*en an individual carries out t*e incorrect actions$
One ot*er classification is iven in -Mc;ensey68o%erts, 155<.@ o'ission A failure to #erfor' an action,
a%sence of res#onse0 ,ron ti'in A action #erfor'ed %ut not at, or ,it*in t*e #ro#er ti'e0 e1traneous act A
unnecessary action not re2uired %y #rocedure or trainin0 trans#osition A correct action %ut on ,ron unit,
syste', or co'#onent0 ,ron selection A selectin t*e ,ron ite', control, action, etc0 ,ron se2uence A
#erfor'in t*e correct actions %ut in t*e ,ron se2uence0 'isco''unication A not co''unicatin or
receivin infor'ation correctly, or failin to co''unicate or receive at all0 2uantitative error A #erfor'in t*e
task to e1cess, or insufficiently0 2ualitative errors A not #erfor'in t*e task to t*e 2uality re2uired0 ot*er A
anyt*in else$
3. HUMAN ERROR TAXONOMIES
)u'an error 'odels, ta1ono'ies and classification syste's *ave %een develo#ed in atte'#ts to understand
t*e causes of *u'an error$ /*ese 'odels include@ t*e conitive #ers#ective, t*e erono'ic #ers#ective, t*e
%e*avioural #ers#ective, t*e e#ide'ioloical #ers#ective and t*e #syc*osocial #ers#ective -Patterson,
2445.$ De,er 'odels as S%!&, '()$, *eSafe, +heel of $isfortune, S($, %F)(S, tend to look at accidents
as a result of a co'%ination of causes t*at interact ,it* eac* ot*er, so t*ey *ave 'oved fro' focusin on a
sinle ele'ent of accident causation, to lookin at t*e syste' as a ,*ole and t*ey re#resent a syste's or
orani!ational a##roac* to accident investiation -Patterson, 2445.$
Software Harware E!"#ro!$e!t L#"eware -S%!&. ,as develo#ed to enco'#ass *u'an factors into
syste' desin -Patterson, 2445.$ /*e 'odel descri%es *u'anE'ac*ine interactions and identifies ,*ere
areas of failure can occur$ Failures are@ soft,are, *ard,are, environ'ent conditions, and live,are$ "oft,are
refers to t*e docu'ents, #olicies, reulations, and standards0 *ard,are is co'#osed of t*e #*ysical
resources0 environ'ental condition refers to t*e #*ysical environ'ent0 live,are includes #eo#le ,*o are
involved ,it* t*e syste'$ Failures occur in t*e syste' ,*en any one of t*e co'#onents or t*e connections
%et,een co'#onents fails$
I!%#e!t Ca&'e A!a()'#' Met*o -'()$. is %ased on t*ree 'ain %eliefs@ 1. t*e root causes of all accidents
can %e linked to orani!ational deficiencies, 2. *u'an error is inevita%le and 'ust %e acce#ted, and 3. if an
orani!ation is serious a%out accident reduction t*en ne, a##roac*es 'ust %e used, and one 'ust learn
fro' #ast 'istakes -Patterson, 2445.$ +BAM includes esta%lis*in t*e facts, identifyin contri%utin factors
and latent conditions, revie,in t*e ade2uacies of e1istin controls and #rocedures, re#ortin t*e findins,
reco''endin corrective actions, detectin orani!ational factors t*at can identify recurrin #ro%le's, and
esta%lis*in key learned facts t*at can %e distri%uted across t*e co'#any$ +t is very i'#ortant to #oint out
t*at t*e #ur#ose of +BAM is not to 'easure t*e uilt and res#onsi%ility for errors, %ut to use errors to learn
fro' t*e'$
T*e Be*a"#o&ra( Safet) -Be"afe. 'et*od is an e1a'#le of an accident investiation tec*ni2ue t*at
atte'#ts to identify, t*rou* t*e use of erono'ics tools, t*e latent causes of accidents -Patterson, 2445.$
/*e oal is to identify areas ,*ere *u'an error is #ossi%le %efore any errors occur$
+*ee( of M#'fort&!e is ta1ono'y ,it* t*ree concentric s#*eres re#resentin t*e actions of t*e front line
o#erators, local conditions, and orani!ational conditions -O?)are, 2444.$ /*e central s#*ere re#resents
local conditions and it is used to e1#lain ,*at *a##ened$ /*e ne1t s#*ere s*o,s orani!ational conditions,
and t*e outer re#resents t*e interactions ,it* t*e environ'ent and t*ese t,o s#*eres *el# define ,*y an
accident occurred$
+n Sw#'',C*ee'e Moe( -S($. accidents result fro' a %reakdo,n ,it*in t*e syste' ,*ic* are a
co'%ination of active failures and latent conditions -8eason1554, 155<.$ Active failures are t*e unsafe acts
of t*ose directly in contact ,it* t*e syste' and are 'ost often associated ,it* accidents$ /*ese failures can
%e classified as errors or violations and intended or unintended actions$ Fnintended errors are classified as
sli#s and la#ses and t*ey are associated ,it* auto'atic actions and include result fro' 'e'ory or attention
la#ses$ +ntended errors are classified as 'istakes ,*ic* occur ,*en an t*e individual fails to carry out t*e
action as intended or carries t*e action out as intended, %ut t*e action ,as t*e incorrect res#onse for t*e
situation$ Violations are intended actions t*at are carried out ,it* ,ilful disreard to t*e esta%lis*ed rules and
2
reulations$ Gatent conditions of a syste' often o unnoticed until an adverse event occurs$ /*ese latent
conditions take t,o for's, t*ose t*at create error #rovokin conditions and t*ose t*at create ,eaknesses in
syste' defences$ 8eason revie,ed t*is 'odel several ti'es, %ut eac* version defines t*e relation %et,een
active failures and latent conditions$ /*e first version divides t*e syste' into five sections@ t*e su#re'e
decision 'akers, line 'anae'ent, #reconditions for unsafe acts, #roduction activities and defence$ 9",iss
c*eese: occurs ,*en 9*oles: a##ear in sections$ /*e second version co'#rises t*ree %asic sections@
orani!ation, taskHenviron'ent and individual, and t*e defence section e1#anded over t*ese t*ree %asic
sections$ /*e t*ird version of t*e section is #resented %y %arriers, control, defence and #rotection of t*e
syste'$ An e1#lanation of *o, 9*oles: occur is also added$
T*e H&$a! -a%tor' A!a()'#' a! C(a''#f#%at#o! S)'te$ -%F)(S. ,as develo#ed for use ,it* t*e F"
Davy to define t*e latent and active failures t*at ,ere identified in 8eason?s "BM -Patterson, 2445.$
Patterson ,as 'odified )FAB" into )u'an Factors Analysis and Blassification "yste' A Minin +ndustry
-%F)(S,$'. ,it* t*e in#ut of end users to %etter correlate to t*e 'inin industry$ %F)(S classifications and
%F)(S,$' 'odification -in %rackets. are iven as follo,s@
1$ unsafe acts
1$1$ error
1$1$1$skillA%ased -routine disru#tion errors.
1$1$2$decision
1$1$3$#erce#tual
1$2$ violation
1$2$1$routine
1$2$2$e1ce#tional
2$ #reconditions for unsafe acts
2$1$ environ'ental factors
2$1$1$#*ysical environ'ent
2$1$2$tec*noloical environ'ent
2$2$ conditions of o#erator
2$2$1$adverse 'ental state
2$2$2$adverse #*ysioloical state
2$2$3$#*ysicalH'ental li'itations
2$3$ #ersonnel factors
2$3$1$cre, resource 'anae'ent -co''unication and coordination.
2$3$2$#ersonal readiness -fitness for duty.
3$ unsafe su#ervision -unsafe leaders*i#.
3$1$ inade2uate su#ervision -inade2uate leaders*i#.
3$2$ #lanned ina##ro#riate o#erations
3$3$ failed to correct #ro%le'
3$I$ su#ervisory violations -leaders*i# violations.
I$ orani!ational influences
I$1$ resource 'anae'ent
I$2$ orani!ational cli'ate
I$3$ orani!ational #rocess
J$ -outside factors.
J$1$ -reulatory factors.
J$2$ -ot*er factors.

.. HUMAN RELIABILITY ASSESSMENT
By analoy of eneral relia%ility calculation 'odel, *u'an relia%ility for si'#le tasks is calculated as -3*illon,
2445.@
( ) lim
m
M
P Y
m

=


-1.
,*ere - -.. is t*e #ro%a%ility of occurrence of event ., and $ is t*e total nu'%er of ti'es t*at . occurs in
t*e m re#eated e1#eri'ents$
3
K*en ti'e to *u'an error is descri%ed %y statistical distri%utions suc* as nor'al, a''a, e1#onential,
Kei%ull, and 8aylei*, for co'#utin *u'an relia%ility 3*ilon -2445. suests t*e use of t*e ,ellAkno,n
eneral e1#ression -2., irres#ective of ,*et*er t*e *u'an error rate is constant or not@
( )
( )
0
t
t dt
HR t e

=
-2.
,*ere %/-t. is t*e *u'an relia%ility at ti'e t and ( ) t is t*e ti'eAde#endent error rate$
)u'an relia%ility assess'ent -)8A. deals ,it* t*e i'#act of *u'ans on syste' #erfor'ance and can %e
used to evaluate *u'an error influences on t*e syste' -+"O 31414, 2445.$ )8A can %e used 2ualitatively to
identify t*e #otential for *u'an error and its causes so t*e #ro%a%ility of error can %e reduced, or
2uantitatively to #rovide data on *u'an failures$ +n#uts to )8A include@ infor'ation to define tasks t*at
#eo#le s*ould #erfor', e1#erience of t*e ty#es of error t*at occur in #ractice and #otential for error,
e1#ertise on *u'an error and its 2uantification$ Out#uts include@ a list of errors t*at 'ay occur and 'et*ods
%y ,*ic* t*ey can %e reduced E #refera%ly t*rou* redesin of t*e syste', error 'odes, error ty#es causes
and conse2uences, a 2ualitative or 2uantitative assess'ent of t*e risk #osed %y t*e errors$ /*e )8A
#rocess is as it is s*o,n in t*e Fiure 1@
1$ Pro%le' definition, ,*at ty#es of *u'an involve'ents are to %e investiatedHassessedL
2$ /ask analysis, *o, ,ill t*e task %e #erfor'ed and ,*at ty#e of aids ,ill %e needed to su##ort
#erfor'anceL
3$ )u'an error analysis, *o, can task #erfor'ance fail@ ,*at errors can occur and *o, can t*ey %e
recoveredL
I$ 8e#resentation, *o, can t*ese errors or task #erfor'ance failures %e interated ,it* ot*er *ard,are,
soft,are, and environ'ental events to ena%le overall syste' failure #ro%a%ilities to %e calculatedL
J$ "creenin, are t*ere any errors or tasks t*at do not re2uire detailed 2uantificationL
=$ Muantification, *o, likely are individual errors and failures of tasksL
<$ +'#act assess'ent, ,*ic* errors or tasks are 'ost i'#ortant, i$e$ ,*ic* ones *ave t*e *i*est
contri%ution to relia%ility or riskL
7$ Crror reduction, *o, can *i*er *u'an relia%ility %e ac*ievedL
5$ 3ocu'entation, ,*at details of t*e )8A need to %e docu'entedL
)ealt* and "afety C1ecutive in its researc* re#ort for *ealt* and safety in la%oratories ives t*e 'ost
detailed list of 'et*ods for *u'an relia%ility assess'ent, follo,ed %y a %rief overvie, of tools -'et*ods.
,*ic* are #otentially useful$ /*e 'ajority of 'et*ods are develo#ed to %e a##lied in nuclear industry, and
'et*ods for eneral a##lication are )u'an Crror Assess'ent and 8eduction /ec*ni2ue -)CA8/. and
A%solute Pro%a%ility Nude'ents -APN. -Bell 6 )olroyd, 2445.$
HEART is desined to %e a 2uick and si'#le 'et*od for 2uantifyin t*e risk of *u'an error$ +t is a eneral
'et*od t*at is a##lica%le to any situation or industry ,*ere *u'an relia%ility is i'#ortant$ /*e 'et*od is
%ased on #re'ises -Bell 6 )olroyd, 2445.@
A Basic *u'an relia%ility is de#endent u#on t*e eneric nature of t*e task to %e #erfor'ed
A +n O#erfect? conditions, t*is level of relia%ility ,ill tend to %e ac*ieved consistently ,it* a iven no'inal
likeli*ood ,it*in #ro%a%ilistic li'its
A (iven t*at t*ese #erfect conditions do not e1ist in all circu'stances, t*e *u'an relia%ility #redicted 'ay
derade as a function of t*e e1tent to ,*ic* identified Crror Producin Bonditions -CPBs. 'i*t a##ly$
/*ere are nine (eneric /ask /y#es descri%ed in )CA8/, eac* ,it* an associated no'inal *u'an error
#otential -)CP., and 37 Crror Producin Bonditions -CPBs. t*at 'ay affect task relia%ility, eac* ,it* a
'a1i'u' a'ount %y ,*ic* t*e no'inal )CP can %e 'ulti#lied$ /*e key ele'ents of t*e )CA8/ 'et*od are@
classify t*e task for analysis into one of t*e nine (eneric /ask /y#es and assin t*e no'inal )CP to t*e
task, decide ,*ic* CPBs 'ay affect task relia%ility and t*en consider t*e assessed #ro#ortion of effect for
eac* CPB, t*en calculate t*e task )CP$
4
-#/&re 1 )u'an relia%ility assess'ent
AP0 a##roac* is conce#tually t*e 'ost strai*tfor,ard *u'an relia%ility 2uantification a##roac*$ +t si'#ly
assu'es t*at #eo#le can re'e'%er, or even, directly esti'ate t*e likeli*ood of an event, in t*is case, a
*u'an error -Bell 6 )olroyd, 2445.$ /*ere are different APN a##roac*es t*at can %e a##lied to deter'ine
*u'an relia%ility@ Areated individual 'et*od ,*ere individuals 'ake t*eir esti'ates individually and t*en
a eo'etric 'ean of t*ese esti'ates is calculated0 3el#*i 'et*od ,*ere individuals 'ake t*eir esti'ates
inde#endently of eac* ot*er, %ut t*e assess'ents are t*en s*ared, allo,in t*e e1#erts to reassess t*eir
o,n esti'ates %ased on t*e ne, infor'ation0 Do'inal rou# tec*ni2ue ,*ere e1#erts are iven t*e
o##ortunity to discuss t*eir esti'ates and confidentially reAevaluate t*eir assess'ent, BonsensusArou#
5
'et*od ,*ere e1#erts 'eet and discuss t*eir esti'ates, follo,in ,*ic* a consensus on an areed
esti'ate 'ust %e reac*ed$
"te#s to t*e APN #rocedure are -Bell 6 )olroyd, 2445.@
1$ "elect t*e su%jectA'atter e1#erts -"MCs.$ /*e "MCs s*ould %e fa'iliar ,it* t*e tasks %ein assessed
and as 'any assessors as #ractically #ossi%le s*ould %e included$ K*en discussions are re2uired to
reac* a consensus t*e nu'%er of assessors ,ould #refera%ly %e around IA= #eo#le$
2$ Pre#are t*e task state'ents$ /*e clearer t*e task definitions t*e less t*ey are o#en to individual
inter#retation$
3$ Pre#are t*e res#onse %ooklets$ /*e res#onse %ooklets s*ould include scale values t*at reflect t*e
esti'ated rane of t*e true #ro%a%ilities of t*e tasks$
I$ 3evelo# instructions$ /*e res#onse %ooklet s*ould include clear instructions for t*e "MCs$
J$ O%tain jude'ents$ "MCs are encouraed to ,ork t*rou* t*e res#onse %ooklets, startin ,it* t*e tasks
t*at t*ey feel confident assessin$
=$ Balculate interAjude consistency$ /o deter'ine t*e levels of consistency %et,een "MCs an analysis of
variance ,ould %e #erfor'ed$
<$ Areate t*e individual esti'ates$ /*is is ac*ieved %y calculatin t*e eo'etric 'ean$
7$ FncertaintyA%ound esti'ation$ Fncertainty %ounds 'ay %e calculated usin a for' of "eaver and
"till,ell?s -1573. for'ulae or alternatively "MCs can %e asked to esti'ate t*e confidence intervals, t*e
esti'ates %ein areated statistically$
1. HUMAN RELIABILITY ANALYSIS IN MINING
"afety issues in 'inin industry *ave %een considered fro' ancient ti'es$ )enry Fayol, as a 'ine enineer,
#ro#osed safety function as an o%liatory function ,it*in enter#rise$ For t*e #ur#ose of #rovidin *i* level
of safety in 'inin industry t*ere e1ist 'any standards and %ills$ 8elia%ility issues *ave %een considered
'ore or less dee#ly$ +n 'anual -#ser's $anual, 1573. for *u'an relia%ility analysis in 'inin, t*e follo,in
#rocedure ,as #ro#osed@
1$ 3escri#tion of t*e syste' oals and functions in order to deter'ine t*e #osition of *u'ans in a syste'
and t*eir o#erational connections ,it* ot*er syste' ele'ents, reardless of ,*et*er it is e2ui#'ent or
ot*er #eo#le$
2$ 3escri#tion of t*e situational c*aracteristics E co'#rises factors ,*ic* influence t*e 'ode of e1ecutin a
task$ /*e factors can %e cateori!ed in t*ree rou#s
2$1$ e1ternal factors A t*ose outside t*e individual@
2$1$1$situational c*aracteristics E arc*itectural features, 2uality of environ'ent, ,orkin *ours,
availa%ilityHade2uacy of s#ecial e2ui#'ent, orani!ational structure, actions %y su#ervisors, coA
,orkers, union re#resentatives and reulatory #ersonnel, re,ards, reconition, %enefits
2$1$2$No% and /ask +nstructions A #rocedures re2uired, co''unication, cautions and ,arnins, ,ork
'et*ods, #lant #olicies
2$1$3$/ask and C2ui#'ent B*aracteristics, E #erce#tual re2uire'ents, 'otor re2uire'ents, controlA
dis#lay relations*i#s, antici#atory re2uire'ents, +nter#retation, decision 'akin co'#le1ity,
narro,ness of task, fre2uency and re#etitiveness, task criticality, lon and s*ort ter' 'e'ory,
calculation re2uire'ents, feed%ack, continuity, tea' structure, 'anA'ac*ine +nterface
2$2$ internal factors E certain skills, a%ilities, attitudes and ot*er *u'an attri%utes a #erson co'es to t*e
jo% ,it*@
2$2$1$ #*ysioloical factors A #revious trainin, state of current #ractice or skill, #ersonality and
intellience varia%les, 'otivation and attitudes, kno,lede of re2uired #erfor'ance, standards,
#*ysical condition, attitudes %ased on influence of fa'ily and ot*er #ersons or aencies, rou#
identification
2$3$ stressors@
2$3$1$#syc*oloical E suddenness of onset, duration of stress, task s#eed, task load, *i* jeo#ardy
risk, t*reats, 'onotonous, deradin or 'eaninless ,ork, conflicts of 'otives a%out jo%
#erfor'ance, reinforce'ent a%sent or neative sensory de#rivation, distractions, inconsistent
cuein
2$3$2$#*ysioloical E duration of stress, fatiue, #ain or disco'fort, *uner or t*irst, te'#erature
e1tre'es, radiation, Aforce e1tre'es, at'os#*eric #ressure e1tre'es, o1yen insufficiency,
vi%ration, 'ove'ent constriction, lack of #*ysical e1ercise
3$ 3escri#tion of t*e B*aracteristics of t*e Personnel co'#rises definin skills, fitness, e1#erience and
'otivation of #ersonnel, t*eir a%ilities and li'itations, ,*ic* is co'#ared ,it* t*e re2uire'ents of t*e jo%
#osition$
I$ 3escri#tion of t*e No%s and /asks t*at t*e Personnel Perfor' is a detailed analysis of tasks and jo%s$
6
J$ Analysis of t*e No%s and /asks to identify error likely situations and ot*er #ro%le's
=$ "uestin of B*anes to t*e "yste' co'%ines t*e results in order to analy!e and ive #ro#osals for
i'#rove'ent$
Mc;ensey and 8o%erts -Mc;ensey68o%erts, 155<. suested t*e 'et*od of Potential )u'an Crror
+dentification as ada#tation of %a"ardous %uman !rror )nalysis$ /*is 'et*od is undertaken ,it* a tea',
,*ic* s*ould include #eo#le ,*o can ans,er tec*nical 2uestions, ,*o are fa'iliar ,it* t*e duties of #eo#le
in relation to t*e 'ac*inery, and ,*o are a,are of t*e ty#es of accident ,*ic* #eo#le can *ave ,it* #lant
and e2ui#'ent$ /y#ical a##lications include@
P identification of a sinle risky activity ,*ere t*ere is #otential for *u'an error leadin to serious
conse2uences0
P identification of t*e #otential for *u'an error ,*en studyin t*e risks associated ,it* 'inin e2ui#'ent or
'ac*inery0
P identification of t*e #otential for *u'an error ,*en studyin t*e risks associated ,it* a 'odification to a
#rocedure or to e2ui#'ent or 'ac*inery ,*ere t*ere is #otential for *u'an error ,it* serious conse2uences$
/*e study takes t*e follo,in for'@
1$ /*e tea' is %riefed on t*e e2ui#'ent, and on t*e tasks undertaken %y #eo#le around it$
2$ A list is t*en co'#iled of t*e key tasks #erfor'ed, eac* of ,*ic* is t*en su%divided into su%Atasks and
#ossi%ly into ele'ents$
3$ Cac* task ele'ent is t*en studied in turn %y t*e tea', usin a c*ecklist of #ossi%le ty#es of *u'an error,
suc* as descri%ed in t*e #revious c*a#ter
I$ /*en t*e tea' discusses@
0.1. +hat are the possible root causes of such an error2
0.3. +hat factors could increase or decrease the likelihood of the error occurrin2
0.4. +hat actions or factors could increase or decrease the consequences if the error occurs2
0.0. +hat existin safeuards exist to prevent the error bein made, or the adverse consequences
resultin2
0.5. +hat additional safeuards could be suested to prevent the error bein made, or the adverse
consequences resultin2
0.6. +hat actions are needed, in the liht of the foreoin discussion2
2. CONCLUDING REMAR3S
/*e fact t*at ina##ro#riate %e*aviour and errors of *u'ans are t*e 'ost i'#ortant causes of syste' failures
and accidents *as influenced t*at reat attention *as %een devoted to *u'an relia%ility issues in researc*
and #ractice ,ork$ As a result, nu'erous 'odels and 'et*ods for *u'an relia%ility analyses and
assess'ent e1ist as ,ell as 'anuals, reco''endations and #arts of relia%ility and risk standards$ )o,ever,
develo#'ent of ne, 'odels and 'et*ods re'ains a c*allenin t*eoretical task$ An o#en issue is *o,
orani!ation and national culture influence *u'an relia%ility 'odels$ Bonse2uently, t*e issue is ,*et*er
t*ere is a eneral 'at*e'atical 'odel for *u'an %e*aviour ,*ic* could %e directly i'#le'ented in #ractice$
Fro' t*e #ractical #oint of vie,, a##lication and i'#le'entation of e1istin 'anuals and standards are of t*e
'ost i'#ortance$ +n t*is conte1t, t*e lack of a relia%le statistical data%ase of *u'an errors and relia%ility is a
very li'itin factor$
AC3NO+LEDGMENTS
/*is #a#er ,as su##orted %y t*e Ministry of Cducation and "cience, 8e#u%lic of "er%ia, Projects
nu'%er /8334II$
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8