New PDF release: Cognitive Reliability and Error Analysis Method

Risk Management

By E. Hollnagel

The turning out to be dependence of operating environments on complicated know-how has created many demanding situations and result in a great number of injuries. even supposing the standard of association and administration in the paintings surroundings performs a massive position in those injuries, the importance of person human motion (as an immediate reason and as a mitigating issue) is indisputable. This has created a necessity for brand new, built-in ways to coincidence research and threat evaluate.

This publication detailing using CREAM is, accordingly, either well timed and invaluable. It provides an errors taxonomy which integrates person, technological and organizational components in line with cognitive engineering ideas. as well as the required theoretical origin, it offers a step by step description of the way the taxonomy might be utilized to examine in addition to expect functionality utilizing a context-dependent cognitive version.

CREAM can be utilized as a second-generation human reliability research (HRA) strategy in probabilistic protection overview (PSA), as a stand-alone approach for coincidence research and as a part of a bigger layout strategy for interactive structures. specifically, using CREAM will allow approach designers and threat analysts to: • determine projects that require human cognition and consequently depend upon cognitive reliability • confirm the stipulations the place cognitive reliability and resulting possibility will be diminished • offer an appraisal of the results of human functionality on procedure security that are utilized in PSA.

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Sample text

Note that in this case the erroneous action may be noted by the person before the actual consequence has occurred, although it commonly involves an anticipated consequence. It thus refers to the "error as action" category, rather than to any of the two others. ) Figure 3: Error as a internalised category. Although the use of an internalised or subjective criterion is de rigueur for the psychological study of erroneous actions, it is not really significant for the aims of human reliability analysis.

Failed event (hazard) ! Loss of control Abnormal condition I AND , AND I Lack of defence I Failure of control • Normal condition AND I Unexpected event Figure 8: The anatomy of an accident. The basic idea in the "anatomy of an accident" is that the final consequence - the failed event or the hazard - only occurs if a number of things go wrong. In Figure 8, the failed event occurs only if there is a loss of control and a lack of defence. The loss of control occurs only if there is an abnormal condition and a failure of control.

In this case the unexpected event was that someone forgot to turn off the tap for the eye rinsing basin. The failure of control was that in two cases the overflow alarms failed; this meant that the water was able to spill onto the floor and run into the sump without anyone noticing it.

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