Analysis of human error of shift team in the hotte

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Human error analysis of shift team in complex industrial system

in complex industrial system, with the continuous improvement of equipment (hardware and software) reliability, accidents caused by human factors have become one of the most important accident sources [1]. Human reliability analysis (HRA) is an effective method to prevent and reduce human errors in complex industrial systems. In the HRA method, the human error rate prediction technology (Thorp) and the accident sequence evaluation program (ASEP, accord, including laminated materials, fiber-reinforced thermosetting and thermoplastic composites NT sequence evaluation program) consider the supervision of the shift chief operator in the main control room as a recovery factor, This consideration does not trace back in detail the possible errors caused by team members' internal contact, division of labor and "group thinking" tendency. The analysis of team human errors in HRA is lack. The author attempts to analyze the generation process of team errors and their behavior shaping factors (PSF), so that HRA in large-scale complex industrial systems can be more developed and improved, and provide a qualitative basis for the quantification of team human error analysis

2 complex industrial system and human error of team

2.1 complex industrial system

complex industrial system has the following basic characteristics [3]:

(1) human machine interface takes small things as big things, that is, human machine interface is diverse and personnel are diversified

(2) information complexity refers to the diversity of information display methods, large amount of information and rapid change of information

(3) dynamic feature complexity, that is, the hierarchy and relevance of the system are complex

(4) environmental uncertainty and complexity, including physical, organizational, social, psychological and other environments

(5) operation complexity. The main operation characteristics of the system are monitoring, confirmation and control. The operation load under emergency state is several times that of normal operation load in order to test new materials. Nuclear power plants, petrochemical plants, aircraft, railways, etc. are typical complex industrial systems. People's production activities in industrial systems are often completed by team members collectively. Team operation can provide mutual support and help, and reasonable division of labor can improve efficiency and quality, which is particularly significant in complex industrial systems. Team operation can detect and recover human errors, and can also produce errors. The main reason is the so-called "group thinking". The reason for its back is often that the team members can carry out 3-point zigzag test, 4-point zigzag test, sheet metal tensile test, thick plate tensile test, strengthened steel bar tensile test, chain tensile test, fixed part experiment, connecting rod experiment, change fatigue experiment, bending torsion composite fatigue experiment, interactive zigzag fatigue experiment, CT experiment, CCT experiment Gear fatigue experiments and so on put maintaining good interpersonal relationships above finding the best decision-making plan, which may lead to wrong results. Therefore, when considering people's mistakes from the perspective of teams, we should not only consider how they make mistakes, but also consider why they do not correct mistakes and how interpersonal relationships cause mistakes

2.2 team human error is one of the forms of "human error" defined by reason [4]. Reason divides human errors into three types: mis2take, lapse and slip. Errors usually occur in the planning and decision-making process, and negligence basically occurs in the execution of operational actions. The first two errors are closely related to "group thinking", and the latter is more related to the activities of a single member. The error2making process is shown in Figure 1, in which the meaning of personal error and shared error is as follows:

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