| Literature DB >> 34339427 |
Yaju Wu1,2, Kaili Xu1, Ruojun Wang1, Xiaohu Xu1.
Abstract
Human errors are considered to be the main causation factors of high-temperature molten metal accidents in metallurgical enterprises. The complex working environment of high- temperature molten metal in metallurgical enterprises has an important influence on the reliability of human behavior. A review of current human reliability techniques confirms that there is a lack of quantitative analysis of human errors in high-temperature molten metal operating environments. In this paper, a model was proposed to support the human reliability analysis of high-temperature molten metal operation in the metallurgy industry based on cognitive reliability and error analysis method (CREAM), fuzzy logic theory, and Bayesian network (BN). The comprehensive rules of common performance conditions in conventional CREAM approach were provided to evaluate various conditions for high-temperature molten metal operation in the metallurgy industry. This study adopted fuzzy CREAM to consider the uncertainties and used the BN to determine the control mode and calculate human error probability (HEP). The HEP for workers involved in high-temperature melting in steelmaking production process was calculated in a case with 13 operators being engaged in different high-temperature molten metal operations. The human error probability of two operators with different control modes was compared with the calculation result of basic CREAM, and the result showed that the method proposed in this paper is validated. This paper quantified point values of human error probability in high-temperature molten metal operation for the first time, which can be used as input in the risk evaluation of metallurgical industry.Entities:
Year: 2021 PMID: 34339427 PMCID: PMC8328327 DOI: 10.1371/journal.pone.0254861
Source DB: PubMed Journal: PLoS One ISSN: 1932-6203 Impact factor: 3.240
CPCs and their effects on human reliability.
| CPC name | Level | Effect on reliability |
|---|---|---|
| 1. Adequacy of organisation | Very efficient | Improved (+1) |
| Efficient | Not significant (0) | |
| Efficient | Reduced (-1) | |
| Deficient | Reduced (-1) | |
| 2. Working condition | Advantageous | Improved (+1) |
| Compatible | Not significant (0) | |
| Incompatible | Reduced (−1) | |
| 3. Adequacy of man machine interface (MMI) and operational support | Supportive | Improved (+1) |
| Adequate | Not significant (0) | |
| Tolerable | Not significant (0) | |
| Inappropriate | Reduced (−1) | |
| 4. Availability of procedures/plans | Appropriate | Improved (+1) |
| Acceptable | Not significant (0) | |
| Inappropriate | Reduced (−1) | |
| 5. Number of simultaneous goals | Fewer than capacity | Not significant (0) |
| Matching current capacity | Not significant (0) | |
| More than capacity | Reduced (−1) | |
| 6. Available time | Adequate | Improved (+1) |
| Temporarily inadequate | Not significant (0) | |
| Continuously inadequate | Reduced (−1) | |
| 7. Time of day | Day | Not significant (0) |
| Evening | Reduced (−1) | |
| Night | Reduced (−1) | |
| 8. Adequacy of training and expertise | Adequate high experience | Improved (+1) |
| Adequate, limited experience | Not significant (0) | |
| Inadequate | Reduced (−1) | |
| 9. Crew collaboration quality | Very efficient | Improved (+1) |
| Efficient | Not significant (0) | |
| Inefficient | Not significant (0) | |
| Deficient | Reduced (−1) |
HEP interval of each COCOM.
| HEP interval | COCOM |
|---|---|
| 0.00005 < p < 0.01 | Strategic |
| 0.001 < p < 0.1 | Tactical |
| 0.01 < p < 0.5 | Opportunistic |
| 0.1 < p < 1.0 | Scrambled |
Fig 1Relations between original CPC score and control mode (Hollnagel, 1998).
Fig 2Membership curves of each COCOM.
Rules for adjusting CPCs.
| Principal CPC | Dependent CPCs | ||||
|---|---|---|---|---|---|
| CPC1 | CPC3 | CPC6 | CPC7 | CPC8 | |
| CPC2 | CPC3 | CPC4 | |||
| CPC2 | CPC3 | CPC4 | CPC5 | CPC7 | |
| CPC1 | CPC8 | ||||
Fig 3Using the BN for determining the probability distribution of the control modes.
Ranks, human erroneous operations, and cause accidents at different positions.
| No. | Position |
|---|---|
| 1 | Torpedo tankers transport molten iron |
| 2 | Scrap steel workers |
| 3 | Shaker mixing molten iron |
| 4 | Desulfurization injection |
| 5 | Desulfurization and slag removal operation |
| 6 | Converter blowing operation of the steel-making master |
| 7 | Crane operator for lifting of molten steel water tank |
| 8 | Hoisting crane operator who confirms that the hook is in place |
| 9 | Tundish repairman |
| 10 | Operator and controller of oxygen lance for steelmaking |
| 11 | Temperature measurement and sampling operator |
| 12 | Slag dumping operation of shaker |
| 13 | Argon blowing operator of converter |
Input values of BN at different operating positions.
| CPCs No. | CPC levels | (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) | (10) | (11) | (12) | (13) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| CPC1 | Veryefficient | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| Efficient | 0.8 | 0.705 | 0.888 | 0.41 | 0.459 | 0.425 | 1 | 1 | 0.8 | 1 | 0 | 0.195 | 1 | |
| InEfficient | 0.2 | 0.295 | 0.112 | 0.59 | 0.541 | 0.575 | 0 | 0 | 0.2 | 0 | 1 | 0.805 | 0 | |
| Deficient | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC2 | Advantageous | 0.615 | 0.45 | 0.265 | 0.104 | 0.11 | 0.02 | 0.524 | 0.775 | 0.645 | 0.735 | 0 | 0.005 | 0.715 |
| Compatible | 0.385 | 0.55 | 0.735 | 0.896 | 0.89 | 0.98 | 0.476 | 0.225 | 0.355 | 0.265 | 1 | 0.995 | 0.285 | |
| Incompatible | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC3 | Supportive | 0.428 | 0 | 0 | 0 | 0 | 0 | 0.118 | 0.25 | 0.148 | 0 | 0 | 0 | 0.472 |
| Adequate | 0.572 | 1 | 0.85 | 1 | 0.376 | 1 | 0.882 | 0.75 | 0.852 | 0.67 | 0 | 0 | 0.528 | |
| Tolerable | 0 | 0 | 0.15 | 0 | 0.624 | 0 | 0 | 0 | 0 | 0.33 | 0.1 | 0.898 | 0 | |
| Imappropriate | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0.9 | 0.102 | 0 | |
| CPC4 | Acceptable | 0.216 | 0 | 0.211 | 0 | 0 | 0 | 0 | 0 | 0.185 | 0 | 0 | 0 | 0.051 |
| Appropriate | 0.784 | 0.899 | 0.789 | 0.475 | 0.91 | 0.485 | 0.985 | 0.827 | 0.815 | 0.92 | 0.295 | 0.405 | 0.949 | |
| Inappropriate | 0 | 0.101 | 0 | 0.525 | 0.09 | 0.515 | 0.015 | 0.173 | 0 | 0.08 | 0.705 | 0.595 | 0 | |
| CPC5 | Fewer than capacity | 0.47 | 0.586 | 0.396 | 0.177 | 0.241 | 0.045 | 0.625 | 0.84 | 0.635 | 0.595 | 0 | 0.213 | 0.59 |
| Matching current capacity | 0.53 | 0.414 | 0.604 | 0.823 | 0.759 | 0.955 | 0.375 | 0.16 | 0.365 | 0.405 | 1 | 0.787 | 0.41 | |
| More than capacity | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC6 | Adequate | 0.831 | 0.2 | 0.465 | 0.285 | 0.291 | 0.19 | 0.712 | 0.854 | 0.687 | 0.84 | 0.41 | 0.375 | 1 |
| Temporarily inadequate | 0.169 | 0.8 | 0.535 | 0.715 | 0.709 | 0.81 | 0.288 | 0.146 | 0.313 | 0.16 | 0.59 | 0.625 | 0 | |
| Continuously inadequate | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC7 | Day | 0.2 | 0.32 | 0.19 | 0.56 | 0.38 | 0.34 | 0.135 | 0.456 | 0.24 | 0.096 | 0.24 | 0.26 | 0.44 |
| night | 0.8 | 0.68 | 0.81 | 0.44 | 0.62 | 0.66 | 0.865 | 0.544 | 0.76 | 0.904 | 0.76 | 0.74 | 0.56 | |
| Night (yejian) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC8 | Adequate high experience | 0 | 0 | 0 | 0 | 0 | 0 | 0.142 | 0 | 0.276 | 0.06 | 0 | 0 | 0.22 |
| Adequate, limited experience | 1 | 1 | 0.88 | 1 | 1 | 0.344 | 0.858 | 1 | 0.724 | 0.94 | 1 | 1 | 0.78 | |
| Inadequate | 0 | 0 | 0.12 | 0 | 0 | 0.656 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | |
| CPC9 | Very efficient | 0.45 | 0 | 0 | 0 | 0 | 0 | 0.322 | 0.29 | 0.59 | 0.47 | 0 | 0 | 0.792 |
| Efficient | 0.55 | 0.87 | 0.844 | 0.622 | 0.774 | 0 | 0.678 | 0.71 | 0.41 | 0.53 | 0 | 0 | 0.208 | |
| Inefficient | 0 | 0.13 | 0.156 | 0.378 | 0.226 | 1 | 0 | 0 | 0 | 0 | 1 | 1 | 0 | |
| Deficient | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
Fig 4BN reasoning results for operation No. 1.
Control mode and reliability probability value of different operating positions.
| Positions No. | Strategic | Tactical | Opportunistic | Scrambled | Dominant control mode | Crisp value | Human error probability (HEP) |
|---|---|---|---|---|---|---|---|
| (1) | 0.089 | 0.905 | 0.006 | 0 | Tactical | -2.36861 | 0.0043 |
| (2) | 0 | 0.943 | 0.057 | 0 | Tactical | -1.92630 | 0.0118 |
| (3) | 0.001 | 0.956 | 0.043 | 0 | Tactical | -1.94819 | 0.0113 |
| (4) | 0 | 0.861 | 0.139 | 0 | Tactical | -1.84246 | 0.0144 |
| (5) | 0 | 0.904 | 0.096 | 0 | Tactical | -1.88382 | 0.0131 |
| (6) | 0 | 0.504 | 0.496 | 0 | Tactical | -1.59658 | 0.0253 |
| (7) | 0.025 | 0.974 | 0.001 | 0 | Tactical | -2.12433 | 0.0075 |
| (8) | 0.062 | 0.937 | 0.001 | 0 | Tactical | -2.28000 | 0.0052 |
| (9) | 0.097 | 0.896 | 0.007 | 0 | Tactical | -2.39343 | 0.004 |
| (10) | 0.016 | 0.983 | 0.001 | 0 | Tactical | -2.08128 | 0.0083 |
| (11) | 0 | 0.184 | 0.701 | 0.115 | Opportunistic | -1.29503 | 0.0507 |
| (12) | 0 | 0.678 | 0.312 | 0.010 | Tactical | -1.87703 | 0.0133 |
| (13) | 0.259 | 0.741 | 0 | 0 | Tactical | -2.80234 | 0.0016 |
Fig 5HEP curve at different positions.
Comparison of the results from the basic CREAM with the results based on the quantified methodology.
| Position No. | control mode | Human error probability (HEP) | ||
|---|---|---|---|---|
| according to the basic CREAM | according to the methodology pro posed in this research | Probability interval (according to the basic CREAM) | Human error Probability (according to the methodology proposed in this research) | |
| (1) | Tactical | Tactical | 0.001 < p < 0.1 | 4.3×10−3. |
| (11) | opportunistic | opportunistic | 0.01 < p < 0.5 | 5.07×10−2. |
Fig 6Position NO.11 BN diagnostic data diagram.