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ANALYSIS OF AN ACCIDENT IN A CO-GENERATION PLANT: COGNITIVE AND ORGANISATIONAL ISSUES INVOLVED

By A. Di Giulio, P. Trucco and M. Pedrali

Abstract

The need to study and understand operators ’ behaviour is becoming evident to predict potentially dangerous situations. The progressive change in the role of the operators towards supervisory tasks means that it was no longer sufficient to study observable aspects of human performance, as the cognitive processes inducing actions must also be considered. Human and organisational factors are therefore closely integrated, and a full safety assessment will require examination of both factors in addition to a system analysis. The present study uses a second-generation methodology to analyse cognitive errors during an accident in a cogeneration plant. The technique was compared with a methodology derived from Reason’s theory, previously used to analyse the same accident. The results of the study highlights how in dynamic and complex environments, where operators perform mainly cognitive tasks, such kind of analyses provide useful information for an in-depth understanding of the humanmachine system as a whole. Moreover, they helps to identify the critical areas where action should be taken to avoid the repetition of identified errors 1

Year: 2011
OAI identifier: oai:CiteSeerX.psu:10.1.1.195.7741
Provided by: CiteSeerX
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