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All sourcesNASA NTRSDOE OSTI
DOE OSTI2014

One Size Does Not Fit All: Human Failure Event Decomposition and Task Analysis

In the probabilistic safety assessments (PSAs) used in the nuclear industry, human failure events (HFEs) are determined as a subset of hardware failures, namely those hardware failures that could be triggered or exacerbated by human action or inaction. This approach is top-down, starting with hardware faults and deducing human contributions to those faults. Elsewhere, more traditionally human factors driven approaches would tend to look at opportunities for human errors first in a task analysis and then identify which of those errors is risk significant. The intersection of top-down and bottom-up approaches to defining HFEs has not been carefully studied. Ideally, both approaches should arrive at the same set of HFEs. This question remains central as human reliability analysis (HRA) methods are generalized to new domains like oil and gas. The HFEs used in nuclear PSAs tend to be top-down—defined as a subset of the PSA—whereas the HFEs used in petroleum quantitative risk assessments (QRAs) are more likely to be bottom-up—derived from a task analysis conducted by human factors experts. The marriage of these approaches is necessary in order to ensure that HRA methods developed for top-down HFEs are also sufficient for bottom-up applications. In this paper, I first review top-down and bottom-up approaches for defining HFEs and then present a seven-step guideline to ensure a task analysis completed as part of human error identification decomposes to a level suitable for use as HFEs. This guideline illustrates an effective way to bridge the bottom-up approach with top-down requirements.

99 GENERAL AND MISCELLANEOUS↗