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Index
Index terms Links
A Accident causation analysis. See also Root cause analysis system
(RCAS) data collection systems and 255 261 262 human error concept of 41 onion model of 262
Accountability, design process implementation guidelines 347
Action oriented techniques 162 decision/action flow diagram 169 hierarchical task analysis (HTA) 162 operational sequence diagram (OSD) 172 operator action event tree (OAET) 167 signal-flow graph analysis 176
Active human error accident causation analysis 41 defined xvii 43
Activity analysis, error prediction and reduction, data acquisition techniques 157
Age, performance-influencing factors 141
Alarms, control panel design 123
Allocation of function, human factors engineering/ergonomics 63
Anonymity, data collection systems, cultural factors 259
Atmospheric conditions, performance-influencing factors 112
Audit techniques MANAGER, sociotechnical systems 90 93 offshore emergency blowdown operations, case study 334
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Audit techniques (Continued) system-induced error approach, performance optimization 21 traditional safety engineering 54
Authority, performance-influencing factors 145
Automation human factors engineering/ergonomics 63 offshore emergency blowdown operations, audit, case study 340 342
B Behavior modification, traditional safety engineering 48
Black box model 67 68
Blame and punishment corporate culture and 249 253 design process implementation guidelines 347 356
C Case studies 291
approach of 17 22 hydrocarbon leak from pipe 292 offshore emergency blowdown operations, audit 334 overview 291 solvent mischarge in batch plant
described 307 standard operating procedure design for 314
visual display unit design 325
Causation. See Accident causation analysis; Root cause analysis system (RCAS)
Change analysis, root cause analysis system, data collection 284
Checks, performance-influencing factors, task characteristics 127
Chemical process quantitative risk analysis (CPQRA) data collection systems 253
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Chemical process quantitative risk analysis (CPQRA) (Continued) over reliance on, performance-influencing factors (PIFs) 146 task analysis, cognitive 181 186
Circadian rhythm, performance-influencing factors 116
Clarity of instruction, performance-influencing factors, task characteristics 126
Classification of error, cognitive systems engineering 68
Cognitive systems engineering 67 applications of 78
conclusions regarding 84 error prediction 79 error reduction 79 generally 78 root cause analysis using sequential error model 81 summarized 81
classification of errors 68 74 error recovery 76 knowledge-based mistakes 76 rule-based mistakes 74 slips and mistakes 74
generic error modeling system (GEMS) 70 human error perspective of 46 overview of 67 prediction 68 skill-, rule-, and knowledge-based classification 69 71 72 stepladder model
case example 94 described 76
Cognitive task analysis techniques 179 critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183
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Cognitive task analysis techniques (Continued) overview of 179
Cognitive "tunnel vision", defined xvii
Communication offshore emergency blowdown operations, audit, case study 337 performance-influencing factors (PIFs) 142
Complexity, performance-influencing factors 110
Consciousness raising, of human error 3
Consequence analysis, risk assessment 216
Consultants, error prediction and reduction 155
Control actions, human-machine interface 62
Control panel design, performance-influencing factors 121
Corporate culture. See Cultural factors
Critical action and decision evaluation technique (CADET) 180
Critical Human Action Profile (CHAP) 282
Critical incident technique, error prediction and reduction 156
Critical task identification and screening analysis, risk assessment 209 211
Cultural factors blame and punishment 249 253 data collection 259 289 design process implementation guidelines 356 error-inducing conditions 18 rule book culture xix 146
D Danger, performance-influencing factors 110
Data acquisition techniques 154 See also Data collection activity analysis 157 critical incident technique 156 documentation 157
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Data acquisition techniques (Continued) expert consultation 154 observation 156 simulators and mock-ups 158 withholding information technique 160
Data collection 247 See also Data acquisition techniques data types 260
chemical processing industry 260 generally 260
defined 247 implementation and monitoring 287 interpretation 268 methods 266
major incident analysis 267 personnel responsible for 266 reporting form design 266 storage and retrieval 267
organizational factors 255 overview of 247 root cause analysis system 270
change analysis 284 evaluation 285 generally 270 human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274 root cause coding 275 278 279 sequentially timed events plotting procedure (STEP) 273 275 tree of causes/variation diagram 270
set-up 288 systems, generally 249 system types 251
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Data collection (Continued) generally 251 254 incident reporting systems (IRS) 252 near miss reporting system (NMRS) 252 quantitative human reliability data collection system 253 root cause analysis system (RCAS) 253
Decision/action flow diagram, described 169
Decision-making stage human-machine interface 61 offshore emergency blowdown operations, audit, case study 338 340
Demand-resource mismatch view, of human error 15
Design factors error-inducing conditions 18 performance-influencing factors and 106 120 visual display unit design, case study 325
Disciplinary action, traditional safety engineering 53
Documentation error prediction and reduction, data acquisition techniques 157 predictive human error analysis (PHEA) 192
E Emergency situations, performance-influencing factors 149
Emotional control, performance-influencing factors 140
Encystment, defined xvii
Engineering. See Cognitive systems engineering; Human factors engineering/ergonomics; Process safety review procedures; Reliability engineering; Traditional safety engineering
Equipment design, performance-influencing factors 120
Ergonomics checklists 196 See also Human factors engineering/ergonomics (HFE/E) application of 196
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Ergonomics checklists (Continued) examples of 196
Error. See Human error
Error-inducing conditions/ described 18
Error prediction and reduction 153 See also Predictive human error analysis (PHEA) cognitive systems engineering 68 79 81
83 data acquisition techniques 154
activity analysis 157 critical incident technique 156 documentation 157 expert consultation 154 observation 156 simulators and mock-ups 158 withholding information technique 160
ergonomics checklists 196 human error analysis techniques 189
overview of 189 predictive 190 work analysis 194
overview of 153 program benefits 10 risk assessment and 201
See also Risk assessment system-induced error approach, performance optimization 20 21 task analysis 161
action oriented techniques 162 applications of 161 cognitive techniques 179 evaluation of 187
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Error prediction and reduction (Continued) purpose of 161
Error recovery, cognitive systems engineering 76
Events and Causal Factors Charting (ECFC) 282
Event tree, THERP case study 229
Experience, performance-influencing factors 133
Expert consultation, error prediction and reduction 154
External error mode, defined xvii
Externals, defined xvii
F Failure model, risk assessment, quantification process 225
Failure modes effects and criticality analysis (FMECA) over reliance on, management policies 146 performance-influencing factors and 109
False assumptions, case study illustrating 27
Fatigue, performance-influencing factors 115
Fault diagnostic support, performance-influencing factors 128
Fault tree construction human reliability role 202 representation 219
Feedback cognitive systems engineering, stepladder model 76 data collection 259 289 human error 8
G Generic error modeling system (GEMS) 70
Goals, design process implementation guidelines 347
Groups, performance-influencing factors 145
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H Hazard and operability (HAZOP) study
hazard identification by 19 over reliance on, performance-influencing factors (PIFs) 146 performance-influencing factors and 109 risk assessment
critical task identification and screening analysis 211 human reliability role 202 205 206
Hazard identification, HAZOP 19
Health & Safety Executive Research Program (U.K.) 90
Hierarchical task analysis (HTA) case study, solvent mischarge 315 described 162
Hours of labor, performance-influencing factors 113
Human error 1 See also entries under Error benefits of elimination program for 10 case studies of 22 concepts of 39
accident causation analysis 41 generally 39 reliability engineering 40
costs of 5 demand-resource mismatch view of 15 neglect of, rationale for 10 overview of 1 perspectives on 44
cognitive systems engineering 46 67 See also Cognitive systems engineering human factors engineering/ergonomics 44 55 See also Human factors engineering/ergonomics
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Human error (Continued) sociotechnical systems 46 85 See also Sociotechnical systems traditional safety engineering 44 47 See also Traditional safety engineering
probability, defined xvii role of, in accidents 4 system-induced error approach
case study approach illustrating 17 overview of 12 20 practical applications 19
Human error analysis techniques 189 overview of 189 predictive 190 work analysis 194
Human factors assessment methodology (HFAM) data collection systems and 265 design process implementation guidelines 356 performance-influencing factors and 105 109 sociotechnical systems 87 93
Human factors engineering/ergonomics (HFE/E) 55 See also Ergonomics checklists automation and allocation of function 63 evaluation of 67 human error perspective of 44 human-machine interface
control actions 62 decision-making stage 61 generally 56 perception stage 60
information processing and mental workload 62
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Human factors engineering/ergonomics (HFE/E) (Continued) overview of 55 system-induced error approach, performance optimization 19 system reliability assessment and error 65
Human information-processing defined xvii human factors engineering/ergonomics 62
Human-machine interface defined xvii ergonomics checklists 197 human factors engineering/ergonomics 56
control actions 62 decision-making stage 61 generally 56 perception stage 60
inadequate, case study illustrating 24
Human performance evaluation system (HPES) cultural factors 259 personnel responsible 266
Human performance investigation process (HPIP) 278 282
Human reliability assessment methodology for, SPEAR 207 210 defined xvii
Hydrocarbon leak, case study 292
I Identifications, inadequate, case study illustrating 27
Implementation, data collection system 287
Implementation guidelines 345 design process 346
accountability, objectives, and goals 347
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Implementation guidelines (Continued) change management 352 generally 346 incident investigations 356 process and equipment integrity 353 process safety review procedures 348 risk management 351 training and performance 354
overview 345 set-up 357
Incident reporting systems (IRS), described 252
Influence diagram approach (risk assessment) calculations for 241 quantification techniques 238
Influence modeling and assessment systems (IMAS), described 183
Information processing, human factors engineering/ergonomics 62
Inspection, design process implementation guidelines 353
Instruction, clarity of, performance-influencing factors 126 See also Training
Instrumentation scales, inappropriate, case study illustrating 27
Interface. See Human-machine interface
Internal error mechanism, defined xviii
Internal error mode, defined xviii
Internals, defined xviii
International Safety Rating System (ISRS) 54
Investigation management data collection types 262 design process implementation guidelines 356
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J Job aids and procedures, performance-influencing factors 123
K Knowledge-based classification. See Skill-, rule-, and knowledge-based
classification (SRK)
Knowledge-based level of control, defined xviii
Knowledge-based tasks cognitive systems engineering, classification of errors 76 visual display unit design, case studies 328 332
L Labeling
equipment design, performance-influencing factors 120 inadequate, case study illustrating 26
Latent human error accident causation analysis 41 42 data collection and 257 defined xviii 43
Leadership, performance-influencing factors 145 See also Management policies
Lighting, performance-influencing factors, operating environment 111
Locus of control defined xviii performance-influencing factors (PIFs), personality factors 140
M Maintenance, design process implementation guidelines 353
Major incident analysis, data collection methods 267
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Management Oversight and Risk Tree (MORT), root cause analysis system, data collection 273 274 278 284
Management policies design process implementation guidelines 352 error-inducing conditions 18 implementation guidelines, set-up 358 performance-influencing factors (PIFs), organizational and social
factors 145 root cause analysis system, data collection 286
MANAGER performance-influencing factors 105 sociotechnical systems 90 93
Manual variability, defined xviii
Mental model, human factors engineering/ergonomics 61 64
Mental workload, human factors engineering/ergonomics 62
Mindset syndrome cognitive systems engineering 76 defined xviii
Mistakes cognitive systems engineering 74 defined xviii
Mock-ups, error prediction and reduction 158
Monitoring data collection system 287 human factors engineering/ergonomics, automation 64
Motivation, performance-influencing factors 136
N Near miss reporting system (NMRS)
data collection systems 257
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Near miss reporting system (NMRS) (Continued) described 252
Night work, performance-influencing factors 116
Noise, performance-influencing factors 111
O Objectives, design process implementation guidelines 347
Observation, error prediction and reduction 156
Offshore emergency blowdown operations, case studies 334
Operating environment, performance-influencing factors 109
Operating procedures, flawed, case study illustrating 30
Operational sequence diagram (OSD), described 172
Operator action event tree (OAET), de-scribed 167
Operator characteristics 133 experience 133 personality factors 135 physical condition and age 141
Organizational factors data collection
chemical processing industry 265 generally 255
error-inducing conditions 18 failures, case study illustrating 35 human error and 5 ineffective, case study illustrating 32 performance-influencing factors (PIFs) 142 system-induced error approach and 22
Organizational learning, performance-influencing factors 147
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P Partitioned operational sequence diagram (OSD), described 175
Perception stage, human-machine interface 60
Performance-influencing factors (PIFs) 103 applications of 105 classification structures for 107 data collection systems and 264 defined xviii interactions of factors in 148 operating environment 109
chemical process environment 109 physical work environment 111 work pattern 112
operator characteristics 133 experience 133 personality factors 135 physical condition and age 141
organizational and social factors 142 teamwork and communication 142
overview of 103 risk assessment
qualitative human error analysis 212 success likelihood index method (SLIM) 234
task characteristics 120 control panel design 121 equipment design 120 job aids and procedures 123 training 128
variability of performance, normal and emergency situations 149
Performance optimization, system-induced error approach 19
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Performance-shaping factors (PSFs) 103 See also Performance-influencing factors (PIFs)
Personality, performance-influencing factors 135
Personal protective equipment (PPE) performance-influencing factors 120 safety campaigns, traditional safety engineering 51
Physical condition and age, performance-influencing factors 141
Physical work environment, performance-influencing factors 111
Plant investigation, human performance investigation process (HPIP) 282
Policy factors, error-inducing conditions 18 See also Management policies
Population stereotype, defined xviii
Prediction. See Error prediction and reduction
Predictive human error analysis (PHEA) case study, solvent mischarge 319 321 described 190 risk assessment
qualitative analysis methods 218 219 qualitative human error analysis 213
Prevention. See Error prediction and reduction
Probabilistic safety analysis (PSA) 104
Problem solving, implementation guidelines 346
Procedures, performance-influencing factors 123
Process safety review procedures, design process implementation guidelines 348
Production requirements, safety requirements versus 129
Protocol analysis, expert consultation 155
Psychology personality, performance-influencing factors 135 root cause analysis system 286
Punishment. See Blame and punishment
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Q Qualitative human error analysis 211
case study, in SPEAR 217 consequence analysis 216 error reduction analysis 217 overview of 211 performance influencing factor analysis 212 predictive human error analysis (PHEA) 213 task analysis 212
Quality assurance, Total Quality Management (TQM) 253
Quantification, risk assessment, human reliability role in 206 See also Risk assessment: quantification
Quantitative human reliability data collection system 253
Quantitative risk assessment (QRA) 103
R Reactance, defined xviii
Recovery analysis, predictive human error analysis 216
Recovery error, defined xviii 43
Reliability engineering, human error concept of 40
Reporting form design, data collection methods 266
Representation, risk assessment 219
Responsibility failures in, case study illustrating 34 performance-influencing factors 144
Rest pauses, performance-influencing factors 113
Retrieval methods, data collection 267
Risk assessment 201 critical task identification and screening analysis 209 211 defined xviii design process implementation guidelines 351
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Risk assessment (Continued) human reliability role in 202
case study 202 error implications for 205 quantification aspects 206
implementation guidelines 346 overview of 201 qualitative human error analysis 211
case study, in SPEAR 217 consequence analysis 216 error reduction analysis 217 overview of 211 performance influencing factor analysis 212 predictive human error analysis (PHEA) 213 task analysis 212
quantification 222 human reliability role in 206 overview of 222
quantification process 224 quantification techniques 225
influence diagram approach 238 238 success likelihood index method (SLIM) 233 technique for human error rate prediction (THERP) 226
representation 219 system for predictive error analysis and reduction (SPEAR) 207 210
Risk homeostasis, defined xviii
Risk homeostasis theory (RHT), performance-influencing factors 138
Risk-taking, performance-influencing factors 137
Role ambiguity, defined xix
Role conflict, defined xix
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Root cause analysis of, using sequential error model 81 case study, hydrocarbon leak, STEP 297 defined xix
Root cause analysis system (RCAS) See also Accident causation analysis data collection 264 270
change analysis 284 evaluation 285 generally 270 human performance investigation process (HPIP) 278 282 Management Oversight and Risk Tree (MORT) 273 274 root cause coding 275 278 279 sequentially timed events plotting procedure (STEP) 273 275 tree of causes/variation diagram 270
described 253
Root cause coding 275 278 279
Routine violations, case study illustrating 30
Rule-based classification. See Skill-, rule-, and knowledge-based classification (SRK)
Rule-based level of control, defined xix
Rule-based tasks error classification, cognitive systems engineering 74 visual display unit design, case studies 326 328 330
Rule book culture defined xix performance-influencing factors 146
Rules and procedures, performance-influencing factors 123
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S Safety campaigns, traditional safety engineering 50
Safety management system audits, traditional safety engineering 54
Safety requirements, production requirements versus 129
Scheduling, performance-influencing factors 116
Sequential error model. See Skill-, rule-, knowledge-based classification (SRK)
Sequential Timed Event Plotting (STEP) case study, hydrocarbon leak 292 data collection system and 264 design process implementation strategies 357 root cause analysis system 273 275
Shift rotation, performance-influencing factors 116
Signal-flow graph analysis, described 176
Simulators and mock-ups, error prediction and reduction 158
Skill(s) deterioration of, human factors engineering/ergonomics 63 level of, performance-influencing factors 133
Skill-, rule-, knowledge-based classification (SRK) case examples 96 cognitive systems engineering 69 71 72 root cause analysis using 81
Skill-based level of control, defined xix
Skill-based task, visual display unit design, case studies 326 329
Sleep deprivation, performance-influencing factors 113
Slips cognitive systems engineering 74 defined xix
Social factors, performance-influencing factors 142
Sociotechnical approach to human reliability (STAHR). See Influence diagram approach (IDA)
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Sociotechnical systems 85 comparisons among approaches of 93 human error perspective of 46 human factors analysis methodology 87 overview of 85 performance-influencing factors and 105 TRIPOD approach 86 U.K. Health & Safety Executive Research Program 90
Solvent mischarge, in batch plant, case studies 307
Spatial operational sequence diagram (OSD), described 176
Standard operating procedures (SOPs), solvent mischarge in batch plant, case studies 314
Stepladder model case example 94 described 76
Stereotype fixation, defined xix
Stereotype takeover, defined xix
Stimulus operation response team (SORTM) 282
Storage methods, data collection 267
Stress case study illustrating 23 performance-influencing factors
emergency situations 149 operator characteristics 134
risk assessment 235
Success likelihood index method (SLIM) 233
Suddenness of onset, performance-influencing factors 110
System factors. See Organizational factors
System for predictive error analysis and reduction (SPEAR) described 207 210 qualitative human error analysis and 211
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System for predictive error analysis and reduction (SPEAR) (Continued) system-induced error approach, performance optimization 20
System-induced error approach case study approach illustrating 17 data collection and 256 overview of 12 20 practical applications 19
System reliability assessment, human factors engineering/ergonomics 65
T Task analysis 161
action oriented techniques 162 decision/action flow diagram 169 hierarchical task analysis (HTA) 162 operational sequence diagram (OSD) 172 operator action event tree (OAET) 167 signal-flow graph analysis 176
applications of 161 cognitive techniques 179
critical action and decision evaluation technique (CADET) 180 influence modeling and assessment systems (IMAS) 183 overview of 179
evaluation of 187 offshore emergency blowdown operations, audit, case studies 340 purpose of 161 risk assessment, qualitative human error analysis 212
Task characteristics, performance-influencing factors 120
Task modeling, risk assessment, quantification process 224
Teamwork, performance-influencing factors 142
Technique for Human Error Rate Prediction (THERP) case study 229
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Technique for Human Error Rate Prediction (THERP) (Continued) data collection systems 254 described 226 representation, risk assessment 219
Technology, human factors engineering/ergonomics, over reliance on 65
Temporal operational sequence diagram (OSD) 172
Testing, design process implementation guidelines 353
Thermal conditions, performance-influencing factors 112
Time dependency, performance-influencing factors 110
Total Quality Management (TQM) 253
Traditional safety engineering 47 data collection and 255 defined xix disadvantages of 49 disciplinary action 53 error prevention and 48 human error perspective of 44 overview of 47 safety campaigns 50 safety management system audits 54 training 55
Training data collection set-up 289 design process implementation guidelines 354 offshore emergency blowdown operations, audit, case study 336 performance-influencing factors
clarity of 126 task characteristics 128
traditional safety engineering 55
Tree of causes/variation diagram 270
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TRIPOD approach performance-influencing factors and 105 109 sociotechnical systems 86 93
Type A and B personality, performance-influencing factors 141
U Unforgiving environment, described 19
United Kingdom Health & Safety Executive Research Program, sociotechnical systems 90 93
V Vagabonding, defined xix
Variation diagram, tree of causes/variation diagram 271
Verbal protocol analysis, defined xix
Violation error accident causation analysis 42 defined xix 43
Visual display unit design, case studies 325
W Warnings, performance-influencing factors 127
Withholding information technique, error prediction and reduction 160
Work analysis, human error analysis techniques 194
Workload distribution, performance-influencing factors 143
Work pattern, performance-influencing factors 112
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