شناسايي خطاهاي انساني و بررسي فاکتورهاي درون‌سازماني مؤثر بر بروز خطا درصنعت گاز

نویسندگان

1 کارشناس ايمني، شرکت ملي گاز ايران، تهران، ايران

2 گروه ايمني صنعتي، دانشکده بهداشت و ايمني، دانشگاه علوم پزشکي و خدمات بهداشتي درماني شهيد بهشتي، تهران، ايران

3 گروه سلامت ايمني و محيط زيست، دانشکده بهداشت و ايمني، دانشگاه علوم پزشکي و خدمات بهداشتي درماني شهيد بهشتي، تهران، ايران

4 گروه ايمني صنعتي، دانشکده بهداشت و ايمني، دانشگاه علوم پزشکي و خدمات بهداشتي درماني شهيد بهشتي، تهران، ايران

doi
10.22037/meipm.v6i2.23779
چکیده

Background and Objectives: Specialized attention to accidents in various industries has shown that human errors are the main cause of the most of them. Therefore, recognizing the pattern and root causes of the errors are the important approach in understanding and improving safety management in the industry. This study aimed to investigate human errors and effective intra-organizational factors in failure occurrence by using the Human Factors Analysis and Classification System Technique in Iranian gas industry. Materials and Methods: The Human Factors Analysis and Classification System Technique has a hierarchical structure with 19 categories of causative factors (active errors and Hidden Defects) in four levels including, unsafe acts (first level), pre-conditions for unsafe acts (second level) ، unsafe supervision (third level) and organizational impacts (fourth level). In this study, the report of the events leading to the death of the Iranian gas industry from 2008 to 2016 was analyzed by using the main framework Human Factors Analysis and Classification System as well as the checklist developed by the US Department of Defense at four levels was studied. Results: The results of human error analysis based on Human Factors Analysis and Classification System showed that among Intra-organizational Factors 34.2% of causes were categorized in unsafe acts level, 26.3% in unsafe monitoring level, 22.4% in pre-conditions level for unsafe acts and 17.1% was at the level of organizational influences. Conclusion: The presence of high percentage of factors related to human errors, violations, and unsafe monitoring in the results of the present study indicated the need for further focus, accurate assessment and formulation of effective recovery strategies. Also, the results showed that the Human Factors Analysis and Classification System can be used systematically to identify human errors and the causes of its occurrence within the organization and establishing effective and targeted safety interventions in industries such as gas industry. How to cite this article: Pourfatah N, Monazami-Tehrani G, Alibabaei A, Yousefiani M. Identification of Human Errors and Effective Intra-organizational Factors in Failure Occurrence in Gas Industry.Irtiqa Imini Pishgiri Masdumiyat (Safety Promotion and Injury Prevention). 2018; 6(2):91-98.