Human error analysis: Review of past accidents and implications for improving robustness of system design

Since the establishment of the high-technology industry and industrial systems, developments of new materials and fabrication techniques, associated with cutting-edge structural and engineering assessments, are contributing to more reliable and consistent systems, thus reducing the likelihood of losses. However, recent accidents are acknowledged to be linked to human factors which led to catastrophic consequences. Therefore, the understanding of human behavioural characteristics interlaced with the actual technology aspects and organisational context is of paramount importance for the safety & reliability field. This study first approaches this multidisciplinary problem by classifying and reviewing 200 major accident data from insurance companies and regulatory authorities under the Cognitive Reliability and Error Analysis framework. Then, specific attention is dedicated to discuss the implications for improving robustness of system design and tackling the surrounding factors and tendencies that could lead to the manifestation of human errors

Learning from accidents: Investigating the genesis of human errors in multi-attribute settings to improve the organisation of design

Remarkable advances in engineering and system controls in recent times and the consequent development of state-of-the-art technologies are clearly resulting in economic, environmental and safety benefits to the society. Latest disasters, however, put human error in the glare of the media spotlight. The February 2016 train collision in southern Bavaria, Germany, which took 11 lives and left more than 90 people injured, is one of several examples where human errors appear to have played a significant role in a major accident. In this emblematic case, the railway system had multiple safety barriers in place, such as an automatic braking system if a train crosses a stop signal, but the track controller had reportedly disabled it. When he realised the error and tried to warn the drivers, it was too late (BBC, 2016)

Learning from major accidents to improve system design

© 2015 Elsevier Ltd.Despite the massive developments in new technologies, materials and industrial systems, notably supported by advanced structural and risk control assessments, recent major accidents are challenging the practicality and effectiveness of risk control measures designed to improve reliability and reduce the likelihood of losses. Contemporary investigations of accidents occurred in high-technology systems highlighted the connection between human-related issues and major events, which led to catastrophic consequences. Consequently, the understanding of human behavioural characteristics interlaced with current technology aspects and organisational context seems to be of paramount importance for the safety & reliability field. First, significant drawbacks related to the human performance data collection will be minimised by the development of a novel industrial accidents dataset, the Multi-attribute Technological Accidents Dataset (MATA-D), which groups 238 major accidents from different industrial backgrounds and classifies them under a common framework (the Contextual Control Model used as basis for the Cognitive Reliability and Error Analysis Method). The accidents collection and the detailed interpretation will provide a rich data source, enabling the usage of integrated information to generate input to design improvement schemes. Then, implications to improve robustness of system design and tackle the surrounding factors and tendencies that could lead to the manifestation of human errors will be effectively addressed

Investigations on nucleophilic layers made with a novel plasma jet technique

In this work a novel plasma jet technique is used for the deposition of nucleophilic films based on (3-aminopropyl)trimethoxysilane at atmospheric pressure. Film deposition was varied with regard to duty cycles and working distance. Spectral ellipsometry and chemical derivatization with 4-(trifluoromethyl)benzaldehyde using ATR- FTIR spectroscopy measurements were used to characterize the films. It was found that the layer thickness and the film composition are mainly influenced by the duty cycle

Analytic imprecise-probabilistic structural reliability analysis

In this paper analytic expressions are given to evaluate the reliability of systems consisting of components, connected in parallel or series, subject to probability box failure distributions. This development allows engineers to evaluate the structural reliability of systems without having to resort to Optimisation and Monte Carlo simulation, which are costly both in terms of the time spent programming and the time required for computation. The results obtained are also more accurate than the equivalent results calculated by simulation. We compare a worked example for a simple series system to the equivalent result from simulation

Derivative based global sensitivity measures

The method of derivative based global sensitivity measures (DGSM) has recently become popular among practitioners. It has a strong link with the Morris screening method and Sobol' sensitivity indices and has several advantages over them. DGSM are very easy to implement and evaluate numerically. The computational time required for numerical evaluation of DGSM is generally much lower than that for estimation of Sobol' sensitivity indices. This paper presents a survey of recent advances in DGSM concerning lower and upper bounds on the values of Sobol' total sensitivity indices $S\_{i}^{tot}$. Using these bounds it is possible in most cases to get a good practical estimation of the values of $S\_{i}^{tot}$. Several examples are used to illustrate an application of DGSM

THERMAL PERFORMANCE AND FLAME TEMPERATURES ON LPG RADIAL BURNERS IN DOMESTIC COOKERS

The objective is to investigate radial burners through experimental tests, looking for its thermal performance behavior. Gas burners in domestic cookers operate on LPG, typically with two different geometries and five thermal power conditions. Usually, those thermal equipment lacks information on its whole operating conditions range for higher energy conversion efficiency and lower fuel consumption; it is not pointed out by the manufacturer or by energy efficiency labeling, what could result in a recommendation for widely effective performance. Appropriate instrumentation was used to carry out the measurements and methodology used as a guideline regulations from INMETRO/CONPET, ABNT - Brazilian Technical Standards Normative, and ANP - National Agency of Petroleum, Natural Gas and Biofuels. Experimental measurements and uncertainties are for the following parameters: fuel mass consumption (kg.s-1), test time elapsed (s), temperature (°C), water mass (kg) and flame temperature by K-type thermocouples (quantitative) and a thermal camera (qualitative). Main conclusions are: a) Operating domestic cookers with handle position selector on middle position (TP3) provides almost the same temperature rise as maximum fuel consumption (TP5), i.e., ΔT in the water container; b) Heat is better transferred (Qgas → Qwater) with the handle position selector fully opened (TP5@B1) and just before fully opening (TP4@B2); c) A non-linear behavior occurs for ηThermal, when moving forward the handle position selector; maximum efficiency occurs at fully open (TP5@B2) and middle opening (TP3@B1); d) Higher values for TPexperimental occurs for B2, in comparison to B1, in whole operational condition ranges; differences are mainly due to geometric parameters (ARB2/ARB1~0.82). In general, B2 has a better geometric design; e) Uncertainty analysis indicate values lower than ±3%, proving to be a suitable methodology for the experimental results in this work; f) Flame temperatures are entirely consistent with both, ηThermal and heat energy delivered, reaching higher temperature values at TP4 for both burners; 751.5°C (B1) and 830.7°C (B2)

Efficient computational structural reliability analysis of concrete containments

This paper presents probabilistic analysis of structural capacity of pre-stressed concrete containments subjected to internal pressure using the Advanced Line Sampling Method (an efficient advanced Monte Carlo simulation technique, which gives more accurate results than FORM). This task is an important part of level 2 probabilistic safety analysis in the nuclear industry, particularly when a reactor is undergoing design assessment. We compare our calculation with experimental results from two international round robin test exercises (Sandia National Laboratories and Bhabha Atomic Research Centre) and calculations using FORM, which are available in the literature. Since the ultimate structural collapse mode of the structures has already been established, we simply attempt to probabilistically determine the failure pressure of the containment. Our results show close agreement with previous calculations and demonstrate that structural engineers who are not specialists in risk engineering can obtain accurate probabilistic analyses of their models using freely available software