Volume 22, Issue 1 (2025)
ioh 2025, 22(1): 86-107 |
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Shahbazizadeh H, Mohsen Zadeh F M, Gholam Nia R, Monazami Tehrani G, Eskandari D, Hossein Khani D et al . Investigating the role of human error in gas industry maintenance process accidents (case study: gas company). ioh 2025; 22 (1) :86-107
URL: http://ioh.iums.ac.ir/article-1-3651-en.html
URL: http://ioh.iums.ac.ir/article-1-3651-en.html
Hafez Shahbazizadeh 
, Fatemeh Mahnaz Mohsen Zadeh , Reza Gholam Nia , Ghazaleh Monazami Tehrani * , Davood Eskandari , Davood Hossein Khani , Yoosef Faghihnia Torshizi
, Fatemeh Mahnaz Mohsen Zadeh , Reza Gholam Nia , Ghazaleh Monazami Tehrani * , Davood Eskandari , Davood Hossein Khani , Yoosef Faghihnia Torshizi
Shahid Beheshti University of Medical Sciences , ghazaleh.monazami@sbmu.ac.ir
Abstract: (1907 Views)
Background and Aims: With the rapid advancement of technology and the increasing complexity of human–machine systems, the role of human factors in system performance, safety, and reliability has become increasingly critical. Although the physical presence of humans in industrial environments has decreased due to automation, human involvement remains a major contributor to system vulnerability and accidents. Human error has been identified as a dominant cause of occupational accidents, particularly in high-risk industries such as oil and gas. Maintenance activities, due to their technical and organizational complexity, are especially prone to human error. This study aimed to investigate the contribution and characteristics of human errors in maintenance-related accidents in the Iranian gas industry using the TRACEr-OGI method.
Methods: A retrospective analysis of accidents resulting in fatality or extensive damage was conducted in the National Iranian Gas Company between 2009 and 2019. Accident data were collected from paper-based reports (2009–2013) and electronic records (2014–2019). All selected accidents were systematically analyzed using the TRACEr-OGI framework. This method classifies human error across three main domains: incident context (task, information, and equipment errors), operator context (external error modes, cognitive domains, internal error modes, and psychological error mechanisms), and control barriers and recovery measures.
Results: A total of 60 accidents were reviewed, of which 42 were related to maintenance processes. The highest number of accidents occurred in 2011, while the lowest was recorded in 2019. Provincial gas companies accounted for the largest proportion of accidents. Information-related errors and high casualty levels were the most frequently identified contributors to accidents. Within the operator context, action errors, inappropriate selections, and psychological error mechanisms played a significant role in accident occurrence during maintenance activities.
Conclusion: The findings indicate that human error is the primary contributing factor to maintenance-related accidents in the gas industry, particularly errors associated with task execution, violation of procedures, and inadequate supervision. Improving and standardizing maintenance instructions, enhancing training programs, strengthening monitoring systems, and ensuring contractor compliance with operational and drilling standards are essential measures to reduce human error and prevent future accidents.
Methods: A retrospective analysis of accidents resulting in fatality or extensive damage was conducted in the National Iranian Gas Company between 2009 and 2019. Accident data were collected from paper-based reports (2009–2013) and electronic records (2014–2019). All selected accidents were systematically analyzed using the TRACEr-OGI framework. This method classifies human error across three main domains: incident context (task, information, and equipment errors), operator context (external error modes, cognitive domains, internal error modes, and psychological error mechanisms), and control barriers and recovery measures.
Results: A total of 60 accidents were reviewed, of which 42 were related to maintenance processes. The highest number of accidents occurred in 2011, while the lowest was recorded in 2019. Provincial gas companies accounted for the largest proportion of accidents. Information-related errors and high casualty levels were the most frequently identified contributors to accidents. Within the operator context, action errors, inappropriate selections, and psychological error mechanisms played a significant role in accident occurrence during maintenance activities.
Conclusion: The findings indicate that human error is the primary contributing factor to maintenance-related accidents in the gas industry, particularly errors associated with task execution, violation of procedures, and inadequate supervision. Improving and standardizing maintenance instructions, enhancing training programs, strengthening monitoring systems, and ensuring contractor compliance with operational and drilling standards are essential measures to reduce human error and prevent future accidents.
Type of Study: Research |
Subject:
Safety
Received: 2024/06/12 | Accepted: 2025/02/9 | Published: 2025/04/30
Received: 2024/06/12 | Accepted: 2025/02/9 | Published: 2025/04/30
References
1. Cheng C-M, Hwang S-L. Applications of integrated human error identification techniques on the chemical cylinder change task. Applied ergonomics. 2015;47:274-84. [DOI:10.1016/j.apergo.2014.10.008] [PMID]
2. Halvani G, Khosh Akhlagh AH. Advanced Safety Engineering. Tehran: Asaresobhan; 1395.
3. Pakbaz Hr, Amini Nasab A, Delavar A. Identification and Evaluation of Human Errors of Operator of Digger Cabin in Drilling Rig Using the SHERPA Technique. Occupational Hygiene and Health Promotion 2019; 3(3): 156-68. { in Persian} [DOI:10.18502/ohhp.v3i2.1393]
4. Shirmardi E. Human error in process industry and its relationship with work-related accidents and providing solutions to deal with risks and occurrence of human error (Case study of phase 13 Kangan): Tabnak Higher Education Institute ، Safety group;1397. { in Persian}
5. Organization IL. Safety and health statistics 2019 [Available from: https://www.ilo.org/global/statistics-and-databases/lang--en/index.htm.
6. Naghavi Z, Mortazavi SB, Hajizadeh E. Exploring the contributory factors of confined space accidents using accident investigation reports and semistructured interviews. Safety and health at work. 2019;10(3):305-13. [DOI:10.1016/j.shaw.2019.06.007] [PMID] []
7. Mohammadfam I, Zare A, Yazdani Rad S, Dehghani F, Omidi F. Assessment and analysis of studies related human error in Iran: A systematic review. Journal of Health and Safety at Work Vol. 7; No. 3; Autumn 2017.
8. Naghavi-Konjin Z, Mortazavi S-B, Asilian-Mahabadi H, Hajizadeh E. Ranking the occupational incident contributory factors: A Bayesian network model for the petroleum industry. Process Safety and Environmental Protection. 2020;137:352-7. [DOI:10.1016/j.psep.2020.01.038]
9. Hesamodin K. Identifying the factors affecting the incidence of human error in the industrial environment (case study of Phase 2 and 3 refineries of South Pars Gas Complex): Hormozgan University, School of Humanities;1395. {in Persian}
10. Shorrock ST, editor TRACEr and TRACEr-lite: bridging the gap between incident investigation and performance prediction. Safety and Reliability; 2005: Taylor & Francis. [DOI:10.1080/09617353.2005.11690805]
11. Li J, Wang H, Xie Y, Zeng W. Human Error Identification and Analysis for Shield Machine Operation Using an Adapted TRACEr Method. Journal of Construction Engineering and Management. 2020;146(8):04020095. [DOI:10.1061/(ASCE)CO.1943-7862.0001880]
12. Theophilus S, Ekpenyong I, Ifelebuegu A, Arewa A, Agyekum-Mensah G, Ajare T. A technique for the retrospective and predictive analysis of cognitive errors for the oil and gas industry (TRACEr-OGI). Safety. 2017;3(4):23. [DOI:10.3390/safety3040023]
13. Baysari MT, Caponecchia C, McIntosh AS. A reliability and usability study of TRACEr-RAV: The technique for the retrospective analysis of cognitive errors-For rail, Australian version. Applied ergonomics. 2011;42(6):852-9. [DOI:10.1016/j.apergo.2011.01.009] [PMID]
14. Azhdari M, Monazzami Tehrani G, Alibabaei A. Investigating the Causes of Human Error-Induced Incidents in the Maintenance Operations of Petrochemical Industry Using Human Factors Analysis and Classification System. J Occup Hyg. 2016;3(4):22-30. DOI: 10.21859/johe-03043. {in Persian} [DOI:10.21859/johe-03043]
15. El Bouti MY, Allouch M. Analysis of 801 Work-Related Incidents in the Oil and Gas Industry That Occurred Between 2014 and 2016 in 6 Regions.
16. Haji Hosini AR. Human Error Engineering: Fanavaran; 1389.
17. AliReza J. Investigation and comparison of human errors in the three units of Abadan Oil Refining Company by CREAM and HEART techniques: Tabnak Higher Education Institute;1396. {in Persian }
18. Graziano A, Teixeira A, Soares CG. Classification of human errors in grounding and collision accidents using the TRACEr taxonomy. Safety science. 2016;86:245-57. [DOI:10.1016/j.ssci.2016.02.026]
19. Halvani GH, Mehrparvar AH, Shamsi F, Rafieenia R, Khani Mouseloo B, Ebrahimi Gh. Risk assessment of human error in Mohr City, Parsian Gas Refinery Company control room operators using systematic human error reduction and prediction approach SHERPA in 2016. Occupational Medicine Quarterly Journal 2017; 9(3): 32-44. {in Persian}
20. Saber A. Quantitative evaluation of human error of control room operators in one of the refineries of the country using the technique of systematic approach to predict and reduce human error: Tabnak Higher Education Institute ، Safety group;1398. {in Persian}
21. Mahdavi S, Dehghani T, Kosari M, KHoshnanond N, Human error analysis of control room operators of Butane-1 unit using HEART and TRACEr technique in petrochemical industry: Association of Ergonomics and Human Factors Engineering;1397 . {in Persian}
22. Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human erroranalysis among petrochemical plant control room operators with human errorassessment and reduction technique. Iran Occupational Health. 2009;6(2):38-50.
23. Shirali GA, Malekzadeh M. Predictive Analysis of Controllers' Cognitive Errors Using the TRACEr Technique: A Case Study in an Airport Control Tower. Jundishapur journal of health sciences. 2016;8(2). [DOI:10.17795/jjhs-34268]
24. abbas Shirali G. Predictive Analysis of Cognitive Errors of Control Room Operators: a Case Study in a Petrochemical Industry. Iranian Journal of Ergonomics| ISSN. 2021;2345:5365.
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