• Title, Summary, Keyword: human error

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A Study of Methodology to Examine Organizational Root Causes through the Retrospect Error Analysis of Railroad Accident Cases

  • Ra, Doo Wan;Cha, Woo Chang
    • Journal of the Ergonomics Society of Korea
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    • v.34 no.2
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    • pp.103-113
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    • 2015
  • Objective: This study proposes a systematic process to present the analysis methods and solutions of organizational root causes to human errors on the railroad. Background: In fact, organizational root cause such as organizational culture is an important factor in the safety concerns on human errors in the nuclear power plant, railroad and aircraft. Method: The proposed process is as follows: 1) define analysis boundary 2) select human error taxonomy 3) perform accident analysis 4) draw root causes with FGI 5) review root causes analysis with survey 6) chart analysis of root causes, and 7) propose alternatives and solutions. Results: As a result, root causes of the organizations like railroad and nuclear power plant came from the educational problems, violations, payoff system, safety culture and so forth. Conclusion: The proposed process does predict potential railroad accident through retrospect error analysis by building new human error taxonomies and problem solution. Application: This study would contribute to examination of the relationship between human error-based accidents and organizational root causes.

A study on a design of developed-ERES/WCS using the ASR and fuzzy set theory as a part of human interface technique (Human interface 기술의 일환으로서 ASR과 fuzzy set theory를 이용한 developed-ERES/WCS 설계에 관한 연구)

  • 이순요;이창민;박세권
    • 제어로봇시스템학회:학술대회논문집
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    • pp.76-81
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    • 1988
  • As a means of human interface, this study designs Developed-ERES/WCS with voice recognition capability and fuzzy set theory. In the advanced teleoperator system, when an error occurs on the automatic mode, the error is recovered after the automatic mode is changed into the manual mode intervened by a human. The purpose of this study is to reduce human work load and to shorten error recovery time during error recovery.

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A State-of-the-Art Report on the Current Human Error Studies: What and How to Cope with (인적 오류 연구의 동향과 과제: 어떻게 하고 있으며, 무엇이 필요한가?)

  • Lee, Yong-Hee
    • Journal of the Ergonomics Society of Korea
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    • v.30 no.1
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    • pp.1-8
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    • 2011
  • While human error has been one of the main technical issues from the early era of human factors engineering, it still remains hot and somewhat vague due to the various types of the concepts and words on human errors in practice. There may be some technical limitations hindering human error prevention activities. This paper introduces the human error activities described in the papers if this issue of ESK Journal according to a few criteria proposed for more effective technical review. And two basic technical issues are discussed on the concepts, perspectives, and classifications about human errors. Each activity shows its own artifacts associated with the safety purpose and the nature of the industry. This paper also provides a set of new technical bases proposed for a more effective management of human errors by considering the dependability, representativeness, and structuredness of human errors. Additionally, this paper includes some new challenges over the current prevention-oriented activities; positive utilizations of human errors to training/education, advertisements, fun and entertainments, and nudges.

A Study on Human Error for safety improvement in railway industry (철도산업에서 안전성 제고를 위한 인적오류 연구)

  • Heo, Eun-Mee;Byun, Seong-Nam
    • Proceedings of the KSR Conference
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    • pp.2040-2047
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    • 2010
  • Railway system which has latent loss of lives and property by big accident with that human error such as locomotive driver, manager, signaller, and the others involved. So human error management is needed to control this complex system and to confirm safety of it. Rail human error research for managing human resource has grown rapidly in both quantity and quality of output over the past few years. The continual influences of safety concerns, new technical system opportunities, reorganization of the business, needs to increase effective, reliable and safe use of capacity, and increased society, media and government interest have now accelerated rail human factors research programmes in several countries. The objective of this research is to improve safety and to reduce accidents in korean railway system, through the application of research results to the investigation of requirement for human error.

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A method of human error management in chemical process industries (화학공정산업의 인적오류 제어 방법)

  • Jo Young-Do;Park Kyo-Shik;Park Heui-Joon
    • Journal of the Korean Institute of Gas
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    • v.7 no.2
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    • pp.42-47
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    • 2003
  • To prevent major accident from toxic gas release, explosion, or fire in chemical processes, it needs dynamic control of human error with mechanical failure. Although most of major accidents occur with a coupling of human error and mechanical failure, numbers of researches have studied human error and mechanical reliability independently, but no where cross each other, to reduce the risk in the process. This work focuses on the coincidence of human error and mechanical failure for management of human error, and on some important performance shaping factors to propose a method for improving safety effectively of the process industries.

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The Common Mode Failures Analysis of The Redundant System with Dependent Human Error (의존적 인간 실수를 고려한 중복 시스템의 Common Mode Failures의 분석)

  • Myung Ki Kim;Soon Heung Chang
    • Nuclear Engineering and Technology
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    • v.15 no.4
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    • pp.229-235
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    • 1983
  • Common Mode Failures (CMFs) have been a serious concern in the nuclear power plant. There is a broad category of the failure mechanisms that can cause common mode failures. This paper is a theoretical investigation of the CMFs on the unavailability of the redundant system. It is assumed that the total CMFs consist of the potential CMFs and the dependent human error CMFs. As the human error dependence is higher, the total CMFs are more effected by the dependent human error. If the human error dependence is lower, the system unavailability strongly depends on the potential CMFs, rather than the mechanical failure or the dependent human error. And it is shown that the total CMFs are dominant factor to the unavailability of the redundant system.

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Product Safety Activities for Preventing Human Errors Related with Consumer Products (소비자 제품과 관련된 휴먼에러의 예방을 위한 제품안전활동)

  • Lim, Hyeon-Kyo;In, Byung
    • Journal of the Ergonomics Society of Korea
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    • v.30 no.1
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    • pp.9-17
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    • 2011
  • Consumer products are produced on the premise that consumers can use their products safely and effectively no matter how serious human errors they may make. However, different careers and educational experiences of them may induce diverse human errors when they want to use them. In that sense, not a few policies to reduce human errors may show some implications for human error prevention and industrial design of consumer products. In this paper, producers' safety efforts required by Product Liability(PL) Act were reviewed in view of human error prevention, and legal aspects of manufacturers' responsibility for consumer products were discussed in relation to Product Liability Act. Then, principal approaches for them were introduced under the title of System Safety Precedence. After that, major key points for preventing human errors related with consumer products - such as ergonomic design and effective labeling - were discussed with reference to ISO standards. Therefore, it was shown that all the efforts required by PL Act would be correspondent to human error prevention in the whole manufacturing processes if understood by ergonomists. To make a conclusion, it could be said that, for human error prevention, the principle of System Safety Precedence would be indispensable, and that all the efforts for preventing human errors should be systematically organized in Product Safety Management Systems.

Design of Menu Driven Interface using Error Analysis (에러 분석을 통한 사용자 중심의 메뉴 기반 인터페이스 설계)

  • Han, Sang-Yun;Myeong, No-Hae
    • Journal of the Ergonomics Society of Korea
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    • v.23 no.4
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    • pp.9-21
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    • 2004
  • As menu structure of household appliance is complicated, user's cognitive workload frequently occurs errors. In existing studies, errors didn't present that interpretation for cognitive factors and alternatives, but are only considered as statistical frequency. Therefore, error classification and analysis in tasks is inevitable in usability evaluation. This study classified human error throughout information process model and navigation behavior. Human error is defined as incorrect decision and behavior reducing performance. And navigation is defined as unrelated behavior with target item searching. We searched and analyzed human errors and its causes as a case study, using mobile phone which could control appliances in near future. In this study, semantic problems in menu structure were elicited by SAT. Scenarios were constructed by those. Error analysis tests were performed twice to search and analyze errors. In 1st prototype test, we searched errors occurred in process of each scenario. Menu structure was revised to be based on results of error analysis. Henceforth, 2nd Prototype test was performed to compare with 1st. Error analysis method could detect not only mistakes, problems occurred by semantic structure, but also slips by physical structure. These results can be applied to analyze cognitive causes of human errors and to solve their problems in menu structure of electronic products.

An Experimental Evaluation on Human Error Hazards of Task using Digital Device (디지털 기기 기반 직무 수행 시 인적오류위험성에 대한 실험적 평가)

  • Oh, Yeon Ju;Jang, Tong Il;Lee, Yong Hee
    • Journal of the Korean Society of Safety
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    • v.29 no.1
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    • pp.47-53
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    • 2014
  • The application of advanced Main Control Room(MCR) is accompanied with lots of changes and different forms and features through the virtue of new digital technologies. The characteristics of these digital technologies and devices give many opportunities to the interface management, and can be integrated into a compact single workstation in advanced MCR so that workers can operate the plant with minimum physical burden under any operation conditions. However, these devices may introduce new types of human errors and thus a means to evaluate and prevent such errors is needed, especially those related to characteristics of digital devices. This paper reviewed the new type of human error hazards of tasks based on digital devices and surveyed researches on physiological assessment related to human error. An experiment was performed to verify human error hazards by physiological responses such as EEG which was measured to evaluate the cognitive workload of operators. And also, the performances of four tasks which are representative in human error hazard tasks based on digital devices were compared. Response time, ${\beta}$ power spectrum rate of each task by EEG, and mental workload by NASA-TLX were evaluated. In the results of the experiment, the rate of the ${\beta}$ power was increased in the task 1 and task 4 which are searching and navigating task and memory task of hierarchical information, respectively. In case of the mental workload, in most of evaluation items, task 1 and 4 were highly rated comparatively. In this paper, human error hazards might be identified by highly cognitive workload. Conclusively, it was concluded that the predictive method which is utilized in this paper and an experimental verification can be used to ensure the safety when applying the digital devices in Nuclear Power Plants (NPPs).

Analysis of human errors involved in Korean nuclear power plant trips (국내 원자력발전소 인적오류사례의 추이 분석)

  • 이정운;이용희;박근옥
    • Journal of the Ergonomics Society of Korea
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    • v.15 no.1
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    • pp.27-38
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    • 1996
  • A total of 77 unanticipated trip cases induced by human errors in Korean nuclear power plants were collected from the nuclear power plant trip event reports and analyzed to investigate the areas of high priority for human error reduction. Prior to this analysis, a classification system was made on the four task-related categories including plant systems, work situations, task types, and error types. The erroneous actions affecting the unanticipated plant trips were indentified by reviewing carefully the description of trip events. Then, the events with erroneous action were analyzed by using the classification system. Based on the results for the individual cases, human error occurrences were counted for each of the four categories, also for the selected pairs of categories, to find out the relationships between the two categories in aspects of human errors. As a result, the plant systems, work situations, and task types, and error types which are dominant in human error occurrences were identified.

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