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ioh 2025, 22(1): 78-104 |
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Shahbazizadeh H, Mohsen Zadeh F M, Gholam Nia R, Tehrani regularity 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) : 6
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 Tehrani regularity * , Davood Eskandari , Davood Hossein Khani , Yoosef Faghihnia Torshizi
, Fatemeh Mahnaz Mohsen Zadeh , Reza Gholam Nia , Ghazaleh Tehrani regularity * , Davood Eskandari , Davood Hossein Khani , Yoosef Faghihnia Torshizi
Shahid Beheshti University of Medical Sciences , ghazaleh.monazami@sbmu.ac.ir
Abstract: (143 Views)
Introduction
Today, with the rapid growth and development of technology and the use of novel energies, human-machine systems are going to be much more complex (1). The physical presence of man has faded in the working environment before. Hence, important roles have been assigned to facilities, machinery and automated systems. Despite the Quantitative reduction in human presence in working environments, the role of manpower in function, reliability, and immunity of systems proportionate with the machinery’ complexity and automation augmentation has been increased. One of the human factors affecting human performance is individual factors (2). Human factors are individual factors with physical, mental, and psychological nature (3). “Error is part of man ”. This sentence is defined as a part of our personality. While an organization tries to reach a zero level of errors, it is unreachable. While men work in a complex environment, the error will occur and be enhanced under stress, tiring, and overtime(4). Based on an international work organization report in 2017, more than 2.78 million people died because of work illness or work accidents. Economic losses from these accidents have assigned more than 4 percent of gross national income (5). Job damages were the cause of 14 percent of deaths (about 2.78 million) in 2017. Moreover, approximately 374 million work-related injuries by the aftermath of more than four days of absenteeism from work occur in a year(6). The research results on industrial indicate that human error accounts for more than 90%, 80%, 75%, and 70% in nuclear, procedural, marine, and aviation industries, respectively (7). So, human error is one of the main reasons for accidents in the oil and gas industry. Among 262 working deaths, which have been recorded in the years between 2013 and 2017, 83 percent relate to job accidents (8). Studying the total number of 350 accidents that happened in a treatment unit in the South Pars gas complex, showed that 82 percent of accidents happened because of insecure actions by human error and 18 percent were because of unsafe conditions. While human error analysis is evaluated in different industries, but systematic and comprehensive analysis of it is still needed, especially in the gas and oil industry(9).
Several techniques to Human Error Identification (HEI)[1] have been developed during the last few decades. The highest impact in developing these techniques was performed by Rasmussen et al. (1981), including skills, law, and behavior-based knowledge, as well as Reason (1990) consisting of slips, errors, mistakes, and violations(10).
These methods are as follows Systematic Human Error Reduction and Prediction (SHERPA)[2], General Error Modeling System (GEMS)[3], Cognitive Reliability Error Analysis Method (CREAM)[4], Human Error Identification in System Tool (HEIST)[5], Human Factors Analysis and Classification System Technique (HFACST)[6], Technic for the Retrospective and Predictive Analysis of Cognitive Errors (TRACEr)[7](11, 12).
TRACEr-OGI technique is one of these techniques that can be used predictably or retrospectively. According to the end user's cognitive framework, external factors affect its performance. Furthermore, TRACEr classification allows to analyzer to describe inside and outside modes of error, even though the reason is still undetected [8]. TRACEr-OGI method has been developed by Shorrock and Kirwan (2002), to control air traffic(13). Thephilus et al. (2017) developed the TRACEr method and by resolving defects, used it in the gas and oil industry. TRACEr is a comprehensive and perfect method for predicting and analyzing errors [17].
maintenance are the sums of technical, supervision, and managing activities in the system aging cycle. It’s used for system recovery and maintenance to perform the required function. Error in scheduling, execution, or supervision while maintenance can cause a system’s fault. Hence, have an important role in the unit operation and large accident stopping.
Good management and proper maintenance are vital for system reliability and can reduce vulnerability. For this reason, the present study aims to investigate the role of human errors in the maintenance process of the gas industry using the TRACEr-OGI method(14). Human error is studied in the gas industry in different ways both in Iran and other foreign countries, but here, only the TRACEr-OGI method is used. Additionally, the TRACEr-OGI method includes all effective aspects of individual performance, which is somehow the most complete method for evaluating the contribution of human error in accidents.
Methodology:
For retrospective analysis of accidents by using TRACEr-OGI, a minimum of one death or extensive damage was reported by the Tehran gas office. The reports of years between 2009 and 2013 were paper-based and those of 2014 to 2018 were electronic-based. In the next step, the report of accidents was classified based on the TRACEr-OGI method. The classification process was done by a research group and included the identification of related parts of TRACEr-OGI.
TRACEr-OGI is a modular structure and includes 8 classifications which are divided into 3 groups:
Operator-based error includes external error mode, cognition domain error (includes internal error mode and psychological error mechanism ), and performance shaping factors.
Finally, the last step of TRACEr-OGI is the study of control barriers and recovery issues(12).
Result:
The table below illustrates the total frequency of maintenance process accidents in the four operating sectors of the National Iranian Gas Company from 2009 to 2019, namely the gas transmission businesses, gas refining companies, gas engineering and development companies, and provincial gas companies.
Table 1: An abundance of maintenance processes in four operation areas
Table 1 shows the abundance of maintenance processes in four operation areas, including the gas transferring, treatment, engineering companies, and Provincial gas Companies in years 2009 to 2019.
The frequency of accidents and their abundance during maintenance processes in the national gas companies (2009-2019) are shown in figure 1.
Figure 1: frequency of accidents causes and abundance during maintenance processes
According to Figure 4, the high percentage of human error was classified as information error and then casualty level.
Figure 2: human error percentage in accident occurrence during maintenance processes
Figure 3 shows the human error percentage (operator context) during maintenance processes in Iran's national gas company between the years 2009 to 2019.
Figure 3: Human error percent (operator context) during maintenance processes
The following figure shows the percentage of human error in the sub-categories of external error mode (selection/quality), internal error mode (action), and psychological error mechanism (action) of accidents and maintenance processes of the National Iranian Gas Company in 2009-2019.
Figure 4: the percentage of human error in the sub-categories of external error mode, internal error mode, and psychological error mechanism in the National Iranian Gas Company
Conclusions:
The general conclusion of this research shows that the highest number of accidents occurred in 2011 and the lowest in 2019. Also, provincial gas companies have had the highest number of accidents with 17 incidents. The dominant field for errors was in the field of duty errors, which is mainly affected by the standard operating method, violation, and monitoring, and in the field of internal vacuum operator, which is mainly affected by Actions and wrongdoings. Also, the important incidents include incidents related to ruptures gas leaks and channel collapses (drilling), modifying repair methods to fix leaks, compiling, standardizing, and making available instructions and repair methods for operational staff, the use and compliance of contractors with instructions and Drilling standards are proposed as a solution to reduce and prevent such incidents.
Today, with the rapid growth and development of technology and the use of novel energies, human-machine systems are going to be much more complex (1). The physical presence of man has faded in the working environment before. Hence, important roles have been assigned to facilities, machinery and automated systems. Despite the Quantitative reduction in human presence in working environments, the role of manpower in function, reliability, and immunity of systems proportionate with the machinery’ complexity and automation augmentation has been increased. One of the human factors affecting human performance is individual factors (2). Human factors are individual factors with physical, mental, and psychological nature (3). “Error is part of man ”. This sentence is defined as a part of our personality. While an organization tries to reach a zero level of errors, it is unreachable. While men work in a complex environment, the error will occur and be enhanced under stress, tiring, and overtime(4). Based on an international work organization report in 2017, more than 2.78 million people died because of work illness or work accidents. Economic losses from these accidents have assigned more than 4 percent of gross national income (5). Job damages were the cause of 14 percent of deaths (about 2.78 million) in 2017. Moreover, approximately 374 million work-related injuries by the aftermath of more than four days of absenteeism from work occur in a year(6). The research results on industrial indicate that human error accounts for more than 90%, 80%, 75%, and 70% in nuclear, procedural, marine, and aviation industries, respectively (7). So, human error is one of the main reasons for accidents in the oil and gas industry. Among 262 working deaths, which have been recorded in the years between 2013 and 2017, 83 percent relate to job accidents (8). Studying the total number of 350 accidents that happened in a treatment unit in the South Pars gas complex, showed that 82 percent of accidents happened because of insecure actions by human error and 18 percent were because of unsafe conditions. While human error analysis is evaluated in different industries, but systematic and comprehensive analysis of it is still needed, especially in the gas and oil industry(9).
Several techniques to Human Error Identification (HEI)[1] have been developed during the last few decades. The highest impact in developing these techniques was performed by Rasmussen et al. (1981), including skills, law, and behavior-based knowledge, as well as Reason (1990) consisting of slips, errors, mistakes, and violations(10).
These methods are as follows Systematic Human Error Reduction and Prediction (SHERPA)[2], General Error Modeling System (GEMS)[3], Cognitive Reliability Error Analysis Method (CREAM)[4], Human Error Identification in System Tool (HEIST)[5], Human Factors Analysis and Classification System Technique (HFACST)[6], Technic for the Retrospective and Predictive Analysis of Cognitive Errors (TRACEr)[7](11, 12).
TRACEr-OGI technique is one of these techniques that can be used predictably or retrospectively. According to the end user's cognitive framework, external factors affect its performance. Furthermore, TRACEr classification allows to analyzer to describe inside and outside modes of error, even though the reason is still undetected [8]. TRACEr-OGI method has been developed by Shorrock and Kirwan (2002), to control air traffic(13). Thephilus et al. (2017) developed the TRACEr method and by resolving defects, used it in the gas and oil industry. TRACEr is a comprehensive and perfect method for predicting and analyzing errors [17].
maintenance are the sums of technical, supervision, and managing activities in the system aging cycle. It’s used for system recovery and maintenance to perform the required function. Error in scheduling, execution, or supervision while maintenance can cause a system’s fault. Hence, have an important role in the unit operation and large accident stopping.
Good management and proper maintenance are vital for system reliability and can reduce vulnerability. For this reason, the present study aims to investigate the role of human errors in the maintenance process of the gas industry using the TRACEr-OGI method(14). Human error is studied in the gas industry in different ways both in Iran and other foreign countries, but here, only the TRACEr-OGI method is used. Additionally, the TRACEr-OGI method includes all effective aspects of individual performance, which is somehow the most complete method for evaluating the contribution of human error in accidents.
Methodology:
For retrospective analysis of accidents by using TRACEr-OGI, a minimum of one death or extensive damage was reported by the Tehran gas office. The reports of years between 2009 and 2013 were paper-based and those of 2014 to 2018 were electronic-based. In the next step, the report of accidents was classified based on the TRACEr-OGI method. The classification process was done by a research group and included the identification of related parts of TRACEr-OGI.
TRACEr-OGI is a modular structure and includes 8 classifications which are divided into 3 groups:
- context of the Incident
- Operator context
- Control barriers and recovery Measure
Operator-based error includes external error mode, cognition domain error (includes internal error mode and psychological error mechanism ), and performance shaping factors.
Finally, the last step of TRACEr-OGI is the study of control barriers and recovery issues(12).
Result:
The table below illustrates the total frequency of maintenance process accidents in the four operating sectors of the National Iranian Gas Company from 2009 to 2019, namely the gas transmission businesses, gas refining companies, gas engineering and development companies, and provincial gas companies.
Table 1: An abundance of maintenance processes in four operation areas
| Row | Year | Number of Accidents with Extensive Damage and Death | Gas Refining Companies | Gas Transmission Companies | Gas Engineering and Development Companies | Provincial Gas Companies |
| 1 | 2009 | 2 | 0 | 1 | 0 | 1 |
| 2 | 2010 | 2 | 0 | 0 | 1 | 1 |
| 3 | 2011 | 8 | 1 | 1 | 2 | 4 |
| 4 | 2012 | 5 | 1 | 1 | 0 | 3 |
| 5 | 2013 | 7 | 3 | 2 | 0 | 2 |
| 6 | 2014 | 3 | 1 | 0 | 0 | 2 |
| 7 | 2015 | 4 | 1 | 2 | 0 | 1 |
| 8 | 2016 | 3 | 1 | 1 | 1 | 0 |
| 9 | 2017 | 4 | 0 | 1 | 0 | 3 |
| 10 | 2018 | 3 | 1 | 2 | 0 | 0 |
| 11 | 2019 | 1 | 0 | 1 | 0 | 0 |
| Total | 42 | 9 | 12 | 4 | 17 | |
| Total score | 42 | |||||
| Total Number of Accidents Investigated | 60 | |||||
Table 1 shows the abundance of maintenance processes in four operation areas, including the gas transferring, treatment, engineering companies, and Provincial gas Companies in years 2009 to 2019.
The frequency of accidents and their abundance during maintenance processes in the national gas companies (2009-2019) are shown in figure 1.
Figure 1: frequency of accidents causes and abundance during maintenance processes
According to Figure 4, the high percentage of human error was classified as information error and then casualty level.
Figure 2: human error percentage in accident occurrence during maintenance processes
Figure 3 shows the human error percentage (operator context) during maintenance processes in Iran's national gas company between the years 2009 to 2019.
Figure 3: Human error percent (operator context) during maintenance processes
The following figure shows the percentage of human error in the sub-categories of external error mode (selection/quality), internal error mode (action), and psychological error mechanism (action) of accidents and maintenance processes of the National Iranian Gas Company in 2009-2019.
Figure 4: the percentage of human error in the sub-categories of external error mode, internal error mode, and psychological error mechanism in the National Iranian Gas Company
Conclusions:
The general conclusion of this research shows that the highest number of accidents occurred in 2011 and the lowest in 2019. Also, provincial gas companies have had the highest number of accidents with 17 incidents. The dominant field for errors was in the field of duty errors, which is mainly affected by the standard operating method, violation, and monitoring, and in the field of internal vacuum operator, which is mainly affected by Actions and wrongdoings. Also, the important incidents include incidents related to ruptures gas leaks and channel collapses (drilling), modifying repair methods to fix leaks, compiling, standardizing, and making available instructions and repair methods for operational staff, the use and compliance of contractors with instructions and Drilling standards are proposed as a solution to reduce and prevent such incidents.
[1] Human Error Identification
[2] Systematic Human Error Reduction and Prediction Approach
[3] General Error Modeling System
[4] Cognitive Reliability Error Analysis Method
[5] Human Error Identification in System Tool
[6] Human Factors Analysis and Classification System Technique
[7] Technic for the Retrospective and Predictive Analysis of Cognitive Errors
Article number: 6
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
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