مطالعه خطاهای انسانی در یکی از اتاق های کنترل صنایع پتروشیمی توسط تکنیک CREAM ، با رویکرد ارگونومی شناختی
[پایاننامه]
The> Study of Human Errors in an Industrial Petrochemical Control Rooms Adopting CREAM Method, with a Cognitive Ergonomics Approach>
علوم بهزیستی و توانبخشی university of social welfare and rehabilitation))
، ۱۳۸۹
ذ،۱۶۱ص.
پیوست
چاپی
کارشناسی ارشد
ارگونومی ergonomics
۱۳۸۹/۰۶/۱۴
علوم بهزیستی و توانبخشی university of social welfare and rehabilitation))
s in most of the work environments, such as nuclear, military and chemical industries, human error may result in a catastrophic event. A common characteristic of the large technological systems is that a lot of potentially dangerous materials are reserved in one unit only and they are controlled by control room operators. Control room is indeed the heart of those systems and any error in task performance by the operators may lead to an uncompensated events. Therefore, in this study we aimed to identify and to evaluate human errors in the control room of Bouali Sina petrochemical company using CREAM methodMaterials and methods: This research is a cross sectional and analytical-descriptive study was carried out in the control room of Aromatic unit with 39 operators. First, a job analysis was performed by hierarchical task analysis (HTA) method and then probable control modes and cognitive failures probability were determined using the basic and the extended CREAM methodologies.Results: Base on the results of the basic CREAM method, control modes for the tasks of Action,Board Man and Shift Control, were determined as Opportunistic Control mode; while for the Head Control task it was obtained as Tactical Control mode. Considering the results of extended method of CREAM, from all of the identified error types, execution failure (51.70 ), interpretation failure (19.55 ), planning failure (14.94 ) and observation failure (13.81 ) were determined.Conclusion: According to the basic CREAM method, common performance factors (CPCs) which led to reduce performance reliability were the number of simultaneous goals, time of day (circadian rhythm) and adequacy of training and experience. These factors caused the operators to take an opportunistic control mode. According to the extended CREAM method, most cognitive failures were included execution, interpretation, planning and observation failure. The most important cognitive activities related to the control process in the control room of Bouali Sina petrochemical company were communication, execute, diagnosis, monitor and plan. Accordingly, providing instructions and guidelines for the work procedures, establishing training courses, shift work scheduling, Optimization of the present communication systems and modifications in the control software are necessary to control the above mentioned cognitive failures. Cognitive reliability and error analysis method (CREAM), with a detailed theoretical and focus on the cognitive aspects of human behavior and high sensitivity of this method in identifying cognitive errors in one hand, and considering the cognitive context of the works in the control rooms of the petrochemical industries and high probability of errors in this type of cognitive tasks on the other hand, can be proposed as an effective and useful method to study human errors in the control rooms.Keywords: Human Error, Performance Reliability, Control Room, Technique CREAM,Petrochemical Industries.University of Social Welfare and Rehabilitation Sciences Department of Ergonomics M.Sc. ThesisThesis Title:
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The> Study of Human Errors in an Industrial Petrochemical Control Rooms Adopting CREAM Method, with a Cognitive Ergonomics Approach>