Identification and Evaluation of Human Errors leading to incidents in a gas refineries using Human Factors Analysis and Classification System: Case study gas refinery

Abstract

Background and Objective: Incidents are one of the most important causes of damages in an organization often occurring due to a chain of minor and trivial errors. Each error may have minor consequences, but in synergy, the system invariably heads towards serious and disastrous consequences. Therefore, we aimed to identify human errors leading to incidents in a gas refinery using human factors analysis and classification system (HFACS). Materials and Methods: A retrospective study was performed in a gas refinery. Data regarding incidents were gathered from that center. First, root causes analysis reports (RCA) of incidents occurred during the past eight years were prepared. Then, they were analyzed by using the HFACS model. Results: Most errors were associated with the first level, that is, errors caused by unsafe acts, which in the first level they were related to "violations", in the second level to "physical environment", in the third level to "inadequate supervision", and in the fourth level to "management of resources". Conclusion: Our results showed the causes of accidents and several shortcomings in the refinery. Human errors in an organization can be reduced by utilizing administrative controls, creating an appropriate learning environment, and raising employee awareness at the same time.