An Application of Cognitive Reliability Error Analysis Method for Identification and Evaluation of Human Errors of Control Room Operators in a Cement Manufacturing Company

Human errors and consequently the occurrence of adverse accidents in industries is a possible mishap. The control room is the main center of an industrial system, and any errors during the tasks of the operators can have adverse consequences with irreparable damage. Therefore, this study was conducted to identify and evaluate the human error in the control room of one of a cement manufacturing companies using a cognitive reliability error analysis method to improve the safety status as a necessity.

This is a qualitative and cross-sectional study that was conducted using the cognitive reliability error analysis method in a control room of a cement manufacturing industry. After analyzing the tasks using hierarchical task analysis, the method worksheets were completed through observation; interviews with the
operators, the production manager and shift engineer, and analyzing the related documents of the company. Then, user probabilistic controls and cognitive probability errors were determined using the basic and extended cognitive reliability error analysis method for various tasks.

In this study, 7 tasks of control room operators were analyzed using hierarchical task analysis. The findings of the basic method indicated that the type of control style for tasks of action, control room operator, and shift engineer was opportunistic control and the task of the production manager was tactical control. Based on the results of the extended method, execution error (42.74%), interpretation error (23%), planning error (20.61%), and observation error (13.74%) were obtained from the total number of detected errors.

The positive features of the studied method for maximizing the likelihood of human performance along with the likelihood of recovery of human errors along with minimizing the risk of human error were quite evident in this study. Hence this method is recommended for the determination of the probability of cognitive errors in the control room of other industries