AHFE Open AccessHuman Error, Reliability, Resilience, and Performance
Editors: Ronald Boring
Topics: Human Error, Reliability & Performance
Publication Date: 2024
ISBN: 978-1-964867-08-3
DOI: 10.54941/ahfe1004873
Articles
Human reliability in the German site selection for a nuclear waste repository
In Germany, a geological system is to be created for the final disposal of high-level radioactive waste. Classical methods for assessing human reliability consider people performing tasks in an existing system. This paper is intended to show which reliability aspects need to be addressed to humans in earlier phases of a system development based on typical phases. Also, a method is described for measuring human reliability in the phase of system analysis and system conception for complex and novel research and modeling activities. These are typical of the search for the best possible site for high-level nuclear waste. For the development of reliable systems, reliable human actions are crucial, especially in the early phases of system development. In the later phases, adjustments to the system become increasingly expensive and time-consuming.
Fabian Fritsch, Oliver Straeter
Open Access
Article
Conference Proceedings
Challenges in Applying Human Reliability Analysis in Systems Containing Artificial Intelligence
Can we use the same methods to analyze human reliability, if actions, tasks, and interactions change? This paper discusses three challenges of using traditional static human reliability analysis (HRA) on systems that include AI-elements: 1) how to incorporate and include AI in the quantification of human reliability, 2) how to apply HRA to changing tasks and working conditions, and 3) how to include indirect effects to human reliability.
Martin Rasmussen Skogstad, Ronald Boring, Jan Hayes
Open Access
Article
Conference Proceedings
Model, Method, and Data Issues in Human Reliability Analysis (HRA)
According to the results of the HRA comparison study by USNRC and Halden, the evaluation results are significantly different when comparing the method calculations alone, comparing the experiments alone, and further comparing the method and experiment trends [1]. It is considered that human correspondence characteristics have a large context dependency in plant behavior and operator cognitive mechanism variety, however they are not properly captured. It is said that experiments are required to understand cognitive processes and contexts, and models are required to develop evaluation methods that take cognitive mechanisms and context dependencies into consideration. These data and conclusions, which must be true, are still startling facts. Here, we will examine three comparative studies1.Cognitive Process Analysis Experiment (in House): Joint study of Japanese BWR utilities and vendors. When we estimate Human Error Probabilities including Time Reliability Correlation, we must remind its dependency of accident scenario, culture, crew type, etc. Some insights are useful for HRA method consideration [2].2.Three HRA Model Comparison (in House): Two representative HFEs from two types of reactors in Japan, Pressurized Water Reactor (PWR) and Boiling Water Reactor (BWR), were chosen [3]. HRA method to be used are THERP method, Electric Power Research Institute (EPRI) method, and IDHEAS method [4-6] For both PWR and BWR examples, different HEPs were obtained by different HRA methods also. The scenario analysis, qualitative analysis, and task analysis must be reflected into HEPs.3.USNRC & Halden Model & Experiment Comparison: The model is judged to be underestimated compared to the experiment in one accident scenario and another case, to be overestimated. The dispersion of the calculation results by the method and experimental results are close to three digits [1, 7]. The importance of qualitative scenario analysis was widely recognized, and it became clear that the level of analysis depends largely on the knowledge and experience of analysts. This is because the lack of clear guidance in the HRA methodology has led to discrepancies in the analyst's approach [7].References[1] U.S. Nuclear Regulatory Commission, The International HRA Empirical Study, Lessons Learned from Comparing HRA Methods Predictions to HAMMLAB Simulator Data, NUREG-2127, August 2014. [2] Ujita, H., Kawano, R., Yoshimura, S., An Approach for Evaluating Expert Performance in Emergency Situations, Reliability Engineering and Systems Safety, Vol.47, pp.163- 173, 1995.[3] Hiroshi Ujita, Yoshihiro Ide, ASRAM2020, Asian Symposium on Risk Assessment and Management 2020 Online Virtual Conference, November 30 - December 2, Ideal Way of Method and Data Issues in Human Reliability Analysis (HRA) (1) Extraction of HRA Method Issues by Comparison Analysis & (2) Extraction of Method and Data Issues from Research Survey.[4] A. D. Swain, H. E. Guttmann, “Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications Final Report”, NUREG/CR-1278, August 1983. [5] S. Lewis, et. al., “EPRI/NRC-RES Fire Human Reliability Analysis Guidelines Final Report”, NUREG-1921, July 2012. [6] USNRC, EPRI, “An Integrated Human Event Analysis System (IDHEAS) for Nuclear Power Plant Internal Events At-Power Application”, NUREG-2199, March 2017. [7] Taylor, Claire. Improving scenario analysis for HRA. Probabilistic Safety Assessment and Management, PSAM. 2012.
Hiroshi Ujita
Open Access
Article
Conference Proceedings
The Influence of Set Size in a Dynamic Decision-Making Task
In visual search, increasing the number of elements makes target identification more difficult. Identifying a target becomes even more complex in real world scenarios where operators might need to accumulate evidence across movement patterns – a form of dynamic decision making. In a simple simulation, participants moved their ownship around a water space, while observing movements of three, six, or nine vessels around them, one of which exhibited a hostile behavior. Results indicated that accuracy above chance of hostile ship detection did not differ across set sizes, however participants took more steps as the number of ships increased. Participants generally aggregated far less than the optimal amount of evidence, reflected in the overall average accuracy of 53%. This hints at overwhelming challenges to working memory in these types of dynamic decision-making situations. Implications for real-world scenarios and possible automated aids are discussed.
Colleen Patton, Christopher Wickens, Benjamin Clegg, Cap Smith
Open Access
Article
Conference Proceedings
Nuclear Power Plant Maintenance and Commissioning Activities from the Perspective of HRA: A Comparative Study
The recent Human Reliability Analysis (HRA) method developed by U.S. Nuclear Regulatory Commission, Integrated Human Event Analysis System (IDHEAS), provides a well-grounded model to analyze human errors as well as a promising interface for generalizing and integrating human error data from various sources. Nevertheless, the task context and human performance in different domains, even in different applications within one domain, manifest quite different features which make it elusive to draw an inter-sector or inter-application comparison. In light of this contradiction, one question arises: Can HRA in distinct applications be cross-referenced to one another? Motivated by this, an interview study was conducted as a preliminary attempt to figure out the similarities and differences between two typical activities in the nuclear domain, i.e., maintenance and commissioning, with respect to two vital HRA elements, i.e., error modes and performance shaping factors (PSFs). A total of 21 engineers in a nuclear power plant were recruited to participate in the interview about salient error modes and PSFs in maintenance activities as well as a comparison with commissioning activities. Results show that the two activities share analogous error modes and PSFs on the whole, but vary in the patterns and distributions of each individual PSFs. Hence, results of the present study indicate that human errors in these two comparable activities could be characterized by a unified taxonomy, affording positive evidence for the thrown question. However, the discrepancy in the PSF patterns should never be neglected, which could lead to the divergency of nominal PSF levels and nominal human error probabilities.
Zijian Yin, Hongchao Zhang, Peng Cheng, Peiyuan Wang, Zhizhong Li
Open Access
Article
Conference Proceedings
Data Collection and Analysis of Patient and Document Flow During a Disaster Exercise at a Large Hospital
Disaster drills are effective for understanding and mastering business continuity plans (BCP) and response plans, and for identifying and improving problems, but the time and effort required to collect data is an obstacle. In this study, we developed a smartphone application to easily record the flow of patients and documents: NFC tags are attached to simulated patients and documents used in training, and they are read at each scene using a dedicated application. This tool can record when and where the patient was in the area, and when and where the documents were issued and received. We also propose several visualization and quantitative analysis methods that can be performed using the acquired data.
Yumiko Bito, Taro Kanno, Kazumi Kajiyama, Misumi Yamazaki, Haruka Yoshida, Michihiro Tsubaki, Sachika Sharikura
Open Access
Article
Conference Proceedings
Dynamic Assessment Method for Group Decision-making Errors in Extreme Work Environment Driven by Team Cognitive Model
Due to the task demands, team operating in extreme environments is socially isolated, subject to prolonged physical constraints, and exposed to significant risks. The cognitive functional structure of team was focused, and the submarine team was regarded as a social interaction unit. The cluster of Performance Shaping Factors (PSFs) was reconstructed, incorporating the Team-PSFs groups. In terms of member variability, the three-parameter Weibull distribution function was used to construct the human time performance distribution function. The quantitative models of different team cognitive failure modes were constructed that consider the communication information elements within the team, including individual independent transmission, communication shared transmission, and information transmission. The proposed methodology was validated through simulation in a typical task of manned submarine unpowered diving.
Yidan Qiao, Deng Kai Chen, Wenyi Liao, Lin Ma, Haotian Li
Open Access
Article
Conference Proceedings
Flight Simulation Task Performance Predicts Military Multitasking Better Than Laboratory Measures
Proficient multitasking abilities are essential for conducting military operations. Air Force pilots, for instance, must monitor control panels and respond to radio messages while steering an aircraft. Moreover, infantry soldiers need to collaborate in teams in addition to executing orders. Whether both conditions require the same multitasking abilities is unclear. This raises the question, which mechanism accounts for efficient multitasking behavior. One answer may be that individuals possess a general multitasking ability, enabling them to conduct multitasking at more or less the same level of proficiency regardless of task requirements. Likewise, multitasking performance in military operations may be influenced by the proficiency in employing task-specific skills and abilities to handle high workload conditions, suggesting that only individuals with a certain skill set may be suitable for specific military tasks. Determining which account predicts military multitasking best, may significantly improve soldiers’ success rate. To address this, we recruited 25 officer cadets to perform multitasking in three different environments (laboratory, flight simulation, shooting gallery). In the laboratory, individuals needed to solve math problems and memorize radio signals separately and concurrently. In the flight simulation, individuals steered a hair cross (representative for an aircraft) using a joystick. Additionally, they had to respond to control panels and radio signals, and monitor a tank system. In the shooting gallery, the cadets had to solve math problems and memorize radio signals while shooting at ring targets. Laboratory multitasking and military performance were operationalized by means of a modified version of the multitasking throughput measure, allowing to compare performance modulations across different task conditions. We expected that the cadets’ laboratory multitasking assessment predicted their military performance in the shooting gallery best, given that both settings shared similar task requirements. To test this hypothesis, we conducted Bayesian regression analyses. In contrast to our expectation, we found that a compound score of the flight performance measures predicted military performance best. Both measures also correlated with military service duration. This effect implies that military performance may be related to a general multitasking ability. But further research will be required to test if this effect also translates to other military occupational fields.
Yannik Hilla, Maximilian Stefani, Marco Michael Nitzschner, Wolfgang Mack
Open Access
Article
Conference Proceedings
Investigation of human performance in diagnosing unexpected events at nuclear power plants
Diagnosing unexpected events at nuclear power plants is one of the main control room crew's most critical and challenging tasks. It is crucial to understand human performance in event diagnosis during emergencies to assess the risk of a power plant. This study examines the human performance of the crew diagnosing unexpected events at nuclear power plants. Collecting and analysing simulator data, we investigate the time taken for event diagnosis and the characteristics of diagnosis errors in various unplanned events. Analysis results such as event diagnosis time, unsafe act type, and the possibility of occurrence are expected to provide the proper technical basis for risk assessment or design improvement of the relevant nuclear power plant.
Wondea Jung
Open Access
Article
Conference Proceedings
Field operators' visual inspection practices in the operating Finnish nuclear power plants
In nuclear power plants (NPPs), the integrity of the plant is assured, among other safety measures, by regularly conducted field operator (FO) visual inspection rounds. During these rounds, the FOs tour the NPP and inspect the equipment. Despite the term ‘visual inspection,’ other senses are also used in the task. Previously, no systematic information on visual inspection practices in NPPs has been collected.The objective of the study is to gain an understanding of the visual inspection practices. The goal is to systematically document how visual inspection is conducted, expertise developed, and to compare the practices between the different NPPs. Altogether, five FOs and two trainers, representing all operating NPPs in Finland, participated in the semi-structured interviews. We grouped the plants based on their similarities, resulting in three plant groups.All FOs considered the visual inspection as their most crucial task. During the inspection rounds, the FOs examine the integrity of equipment and appropriateness of the facilities. They record readings and make notes about the equipment; one group uses a paper checklist and two others a tablet with a brief history of the process values. Furthermore, looking, listening, touching, and even smelling form an integral part of inspection rounds for all FOs. The inspection rounds are usually performed by one FO at a time, twice in a 12-hour shift. If something deviant is noticed, another FO often participates in the round. In two groups, rounds may have interruptions due to other tasks, such as separations and reconnections. In contrast, one group reported that the rounds are always performed uninterrupted.In general, vision was reported to be the most critical sense for visual inspection. By looking, the FOs get information about the integrity of the surfaces, perceive the meter readings, and evaluate the appropriateness of the facilities. However, hearing was often reported to be as important as vision. With increasing expertise, FOs can collect information by actively listening for indications of faults within the equipment, such as bearing malfunctions. In addition, tactile sense was found important for detecting deviant temperatures of both rooms and equipment and unusual vibrations. Also, smell can be used to detect, for example, oil leaks.All FOs collaborated with the main control room (MCR) operators to whom the round information was delivered. In addition, the FOs were in contact with the maintenance concerning faults and the cleaning personnel regarding the cleaning matters.The initial training for visual inspection is a classroom learning lasting two to three months. However, the most vital part of the training, in terms of the work in practice, is training during working. Then, the FOs perform rounds under the supervision of experienced FOs for approximately one year. After this period, the work is carried out independently.For the most part, all FOs perform the visual inspection rounds similarly. However, some differences are found, which, at large, seem to be explained by the devices used and the structure of the facilities.
Tomi Passi, Satu Pakarinen, Marja Liinasuo
Open Access
Article
Conference Proceedings
Critical analysis of the interviews in the investigation of accidents in the O&G area – case study of 19 accidents in Brazil
Since the beginnings of the O&G Industry, with the first onshore wells in Pennsylvania, in 1859, and the first offshore wells in California, in 1897, the occurrence of accidents has been frequent and caused injuries and losses. Dealing with something that is unknown, partially or completely - an oil reservoir - is something dangerous in itself, and this is associated with the handling of heavy tools, the risk of explosiveness, the collapse of the well and many other accidental scenarios. It is clear, therefore, that understanding the dynamics of an accident is more than important, it is necessary and, as already stated by several Government Regulators around the world, mandatory for the entire O&G chain. But despite all this history since the 19th century, as well as the obligation imposed by Regulators, there is still no methodological and institutional tradition for analyzing and investigating accidents in the O&G Industry, as there is internationally for Civil Aviation and Nuclear Energy. Particularly in the interviewing of workers, whether injured or not, different forms, approaches and treatments are observed, which makes it difficult to implement the best ways of obtaining information to understand the facts. In this research, based on 19 non-fatal accidents that occurred between 2012 and 2022 in Brazil, a critical analysis of the interview process was developed, studying the documents and reports, as well as re-interviewing the interviewees, but not in relation to the accident , but in relation to how they were treated and conducted during the interview. The perceptions and findings of the research demonstrated that there is significant room for improvement, as there are inconsistencies, mistakes and flaws in the accident investigation interview process.
Josue Franca
Open Access
Article
Conference Proceedings
Data Collection and Analysis of Inter-Area Communication During a Disaster Exercise at a Large Hospital
Hospitals, especially regional disaster base hospitals, play a critical role in saving lives during a disaster. Therefore, it is important for the hospitals to conduct disaster response exercises and thoroughly evaluate the results to understand the current level of response capability and to identify potential problems in disaster response and hospital business continuity. However, because data collection and analysis of disaster exercise requires a lot of manpower and time, such evaluation has not been well conducted so far. Aiming to develop evaluation indices of exercise performance, we collected data on patient and document flow, inter-departmental communication, and exercise participant behavior using video cameras, voice recorders, and NFC tags. Focusing on inter-departmental communication, this paper describes the data collection using voice recorders attached to PHS and reports on an attempt to use a large-scale language model to automatically classify the verbal data into several performative verbs.Methods: We collected data during disaster response exercises conducted at a major hospital in Kanagawa Prefecture, Japan, in 2022 and 2023. This hospital is designated as a regional disaster base hospital, which is expected to play a central role in regional disaster medicine. These two exercises were both designed to accommodate mass casualties caused by a major earthquake. We used a voice recorder that can record a conversation via PHS/smartphone; we can record the voice from both sides with a single voice recorder. We attached this voice recorder to several exercise players in different departments to collect communication data on information sharing and command and control. The conversation data was transcribed and used for the further analysis. We analyzed the conversation content from the viewpoint of performative verbs to calculate the anticipation ratio of inter-departmental communication. Usually, this kind of analysis is done manually, which requires a lot of man-hours. On the other hand, in this analysis, we applied the GPT-4.0 language model to automatically classify the conversations into nine performative verbs: greet, inform, acknowledge, request, query, accept, declare, confirm, and suggest. Results and Discussions: We compare the results obtained by GPT with those of human analysts to evaluate the reliability of the classification. We confirmed that the kappa value is 0.73, which indicates that there is substantial agreement between the GPT and manual classification. Then, we calculated the anticipation ratio, which is the ratio of push to pull information, and is often used as a rough indicator of efficient information sharing. By comparing the ratio between 2022 and 2023, we found that the ratio was higher for the command post in 2023, indicating that the command post in 2023 proactively provided information to other departments in advance before they were asked. Conclusion: Through this study, we confirmed that inter-departmental conversations in the exercise can be clearly recorded with the voice recorder attached to the PHS. We also confirmed that a large language model can be used for the classification by performative verbs, thus saving man-hours in calculating the anticipation ratio.
Hiroki Obara, Taro Kanno, Kazumi Kajiyama, Haruka Yoshida, Misumi Yamazaki, Sachika Sharikura, Michihiro Tsubaki
Open Access
Article
Conference Proceedings
Mitigating Human Error in Civil Aviation: A Cognitive Analysis of Job tasks Using Success Likelihood Index Method (SLIM)
Ground Handlers are responsible for managing the critical operations that take place for the airlines and airport. The efficiency and success of the operations are highly dependent on ground handlers and how they can perform the tasks. Any small accident or a minor incident can also result in huge losses in civil aviation. Previous studies show that one of the leading causes of occurrence of accidents or incidents is human error. Therefore, it is necessary to tackle and understand the probability of occurrence of human error, also known as Human error probability (HEP).Purpose of study: The study wishes to understand which tasks amongst the critical ones performed at the airside have higher HEP, and also to identify the factors that are responsible for the same. This is being done because Human error can have an impact on how the individuals perceive the task. The study is therefore studying the factors that impact the cognitive resilience of individuals leading to human error. Methodology: The study uses the Success Likelihood Index Methodology ( SLIM) along with Fuzzy-AHP to calculate the HEP. Ten experts who have had a minimum amount of seven years of experience in managing ground handlers and safety were screened for the data collection process. Conclusion: The study has found that maintenance tasks have a high probability of human error to occur. It was also found that the experience attached to tasks being performed, along with the time constraints and pressure of performing the task efficiently are factors responsible for the human error to occur while performing the tasks. Therefore, it is essential that the organization is able to allocate rosters accordingly and elevate the experience of the tasks that are being performed.
Ucchita Sharma, T Bangar Raju
Open Access
Article
Conference Proceedings