تحقیقات نظام سلامت (Jul 2022)
Assessment of Human Errors in Control Room Operators of a Cement Manufacturing Company Using Systematic Human Error Reduction and Prediction Approach
Abstract
Background: Despite the advancement of control mechanisms and automation in industrial processes, there is still the chance of human error and accidents. As a result, this study was conducted in the control room of a cement company to identify human errors and propose control methods to reduce them using the Systematic Human Error Reduction and Prediction Approach (SHERPA). Methods: The data for this cross-sectional descriptive study were gathered through task observation, reviewing technical documentation, and interviews. For the selected tasks, a hierarchical task analysis (HTA) was done, and the human errors of each critical task were assessed using SHERPA. Finally, control methods for reducing the risk of identified errors were proposed. Findings: In this study, 9 main tasks and 103 sub-tasks were assigned for the control room operators. The results of the SHERPA showed that out of 204 identified human errors, 45.1% were functional, 35.3% retrieval, 11.3% communication, 44% checking, and 9.3% were selection errors. C2 (55 cases), C3 (32 cases), and 2D (30 cases) had the highest risk levels, whereas 1E (1 case), 1B (2 cases), and 4C (3 cases) had the lowest. Conclusion: The most common errors were those relating to performance and retrieval. Operator training, monitoring systems, smart control system utilization, effective instructions, and suitable control measures can help to significantly reduce the number of human errors that result in accidents.