Human error potential

Another advanced and novel sample preparation technique is online solid phase extraction (online SPE). Although the extraction mechanism is as the same as traditional offline SPE, online SPE offers several advantages. Because sample preparation is carried out during analysis, it eliminates the time needed for sample preparation thus increases throughput significantly. Additionally, because the entire sample is eluted to the LC-MS/MS system, it may increase assay sensitivity. Finally, because there is no manual extraction involved, it may reduce human error, potential contamination, and inconsistent recovery. 

The HAZOP technique can be used to identity human error potential. From a practical point of view, human error and its consequences can occur at all levels of a management structure as well as in the operation of a particular plant or process. Carried out correctly, Technica54 states that a HAZOP study will identify at least 70-75 percent of potential operational and safety problems associated with a particular design process, including human error. 

A hazard is defined as the potential source of harm (3.5). Hazards include both the characteristics of things and the actions or inactions of people. Identifying hazardous human error potential, as well as the physical aspects of hazards, is an important part of the hazard identification process. All risks with which safety practitioners deal derive from hazards. There are no exceptions. For any particular hazard, the first and best approach is to eliminate the hazard. If there are no potentials for harm, there are no hazards. If there are no hazards, there are no risks. Hazards eliminated result in zero risk from those hazards. But, it is not possible to eliminate all hazards. 

It was revealed that most of the events due to a work planning problem where a work procedure is provided occurred during low-power states or startup operations. The reason for this can be inferred as the variable characteristics of plant configuration and dynamics of the low-power states of NPP, which may cause the identification of human error potentials and prediction of physical transition to be difficult. Therefore, the identification of human error possibilities or potentials during low-power states seems not to be an easy task to be accomplished by a list of simple checklist items, but belongs to a hard task that requires a careful investigation on the potential of human error by a concerted effort between experts in plant systems and hiunan errors, and, as necessary, may requires the use of thermal-hydraulic and reactor analysis computer codes. 

An evaluation method to determine the probability that a system-required human action, task, or job will be successfully completed within the required time period and that no extraneous human actions detrimental to system performance will be performed. It provides quantitative estimates of human error potential due to work environment, human-machine interfaces, and required operational tasks. Such an evaluation can identify weaknesses in operator interfaces with a system, quantitatively demonstrate improvements in human interfaces, improve system evaluations by including human elements, and demonstrate quantitative prediction of human behavior. See also ATHEANA (A Technique for Human Error Analysis) Human Error Analysis. 

The failure case - the intention is to identify human error potential and assess reliability when specifically related to the dangerous human errors of commission or omission. In addition, the failure case must identify any human tasks arising fn>m die need to mitigate machine failure. 

The analysis will also look for opportunities for hazard mitigation through identification of human error potential and improved information presentation by comparing the TA with HMI design guidelines from appropriate sectors. In summary, the CTA will enable the safety-related system developer to ... 

To avoid hazard-related incidents resulting in serious injuries, human error potentials must be addressed at the cultural, organizational, management systems, design, and engineering levels, and with respect to the work methods prescribed. 

At a symposium on human error held by the American Society of Safety Engineers in December 2010, it was observed that some practitioners suggested that to resolve human error potential one must first examine the design of workplace and the work methods to determine whether the system in place was designed to be error provocative. 

This initial human factors screening approach identified a number of key areas where further human factors studies were required. This included studies such as workload and manning assessments, training needs analyses and assessments of human error potential due to issues such as changes to run numbers. The actions taken and status of these issues were tracked as part of the overall project hazard log. 

Although there were some developments in the pursuit of an understanding of human error in industrial accidents in the decades inunediately following Heinrich s initial proposals, most notably the work of Bird and colleagues which led to the development of the International Safely Rating System (for example. Bird and Loftus, 1976), the topic remained relatively under researched until concern grew about human error potential in the nuclear industry, particularly after the Three Mile Island incident. 

Although the input, decision, output classification is a very simplistic representation of human information processing, it can be a key tool for identifying fhe causal factors and the best area of focus for remedial action. In addition it provides a systematic, straightforward tool for high-level initial identification of human error potential. 

To fully capitalise on the contribution of ergonomics/hnman factors to reduce the likelihood of designed-in human error potential however, the EMESRT approach will need to be expanded to apply to underground mining equipment. At the time of writing (2009) this expansion of EMESRT is in progress. 

There is no doubt that a great deal of information is available to enable the designers in mining equipment companies to minimise the tendency toward designed-in human error potential. Equally, as the EMESRT initiative shows, this information is being made available in mnch more accessible/user-friendly ways. 

Also of benefit in this area is a greater and more systematic consideration of both human error and the factors which predispose human error potential during accident/incident investi tion. This is discussed extensively in Chapter 9. 

In a study undertaken of human error potential at a South African coal mine (Simpson and Talbot, 1994) it was noticed that following the inby journey the driver/assistant uncoupled the loco from the mansets after which the driver drove... 

Review human error potential by observation (see Chapter 10 for more detail), and examination of relevant risk assessments and aceident/near miss investigations. 

Observe operation for human error potential (in effect re-creating the observations undertaken in 1 above) and collate with information from 12, 13, and 14. 

By the increased use of what can be described as Case for Safety risk assessments and, in the process, ensuring specific consideration of human error potential. 

Human error potential in conventional risk assessment Conventional risk assessment in the present context is the process outlined above applied routinely to tasks, operations or workplaces where the ptrrpose is to iderrtily hazards, assess risks and decide whether such risks are adeqrrately controlled. 

A simple process of considering how human error could trigger a hazard to materialise and, therefore, a risk to exist, will provide a systematic basis on which to identify safety related human error potential and then, as a natural progression of the risk assessment process, allow appropriate controls to be identified and implemented. 

Similarly, by systematically considering human error potential when assessing the effectiveness of current control measures (or evaluating the utility of new ones), additional control measures canbe put in place to ensure that all the measures taken can be reasonably assumed to be effective. This process should also then trigger issues to be checked in routine monitoring (both informal, such as supervisors keeping an eye on what is done and formal, for example, routine auditing). 

It is evident that the risk assessment Case for Safety approach can deliver preemptive safety assnrance, both generally and specifically, in relation to human error potential. This is not only for new eqiripment, systems and operations generally, but even for new eqnipment, systems and operations which were previously considered to be of potentially very high risk. 

Several techniques have been developed or modified to identify human error potential including, for example ... 

One technique for the identification human error potential, the Potential Human Error Audit, has been developed in (and specifically for) the mining industry. This was developed initially in the UK tmder British Coal and Eiteopean Coal and Steel Community funding (see Simpson et al., 1994 and summarised in Simpson, 1994). The technique was also subsequently used in South African mining operations both under SIMRAC funding (see Simpson et al., 1996) and direct consultancy (see Simpson and Talbot, 1994). 

There is another approach, the Behaviouially Based Safety (BBS) techniques, which should be mentioned for, although they do not address human error potential... 

Despite the above assurance that the process outlined in not significantly different, in principle, to that already adopted in many organisations it will undoubtedly require more time and more systematic approaches to be used routinely. This, in itself, may be a barrier to adopting such an approach however, the fact that it is fundamentally cmcial to routinely identify human error predisposing factors (particularly those which are common and therefore likely to represent latent failures) can be seen clearly by revisiting some of the examples of human error potential given in Chapters 3-8. 

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