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Radiation Physics and Chemistry: Francesco Castiglia, Mariarosa Giardina, Elio Tomarchio
Radiation Physics and Chemistry: Francesco Castiglia, Mariarosa Giardina, Elio Tomarchio
Radiation Physics and Chemistry: Francesco Castiglia, Mariarosa Giardina, Elio Tomarchio
H I G H L I G H T S
THERP and HEART integrated methodology is proposed to investigate operator errors during high-dose-rate treatment.
The new approach is based on fuzzy set concept to rank an exhaustive list of erroneous tasks.
The results allow to achieve a better understanding of health hazards in the radiotherapy treatment process.
art ic l e i nf o a b s t r a c t
Article history: THERP and HEART integrated methodology is proposed to investigate accident scenarios that involve
Received 1 October 2014 operator errors during high-dose-rate (HDR) treatments. The new approach has been modified on the
Accepted 23 December 2014 basis of fuzzy set concept with the aim of prioritizing an exhaustive list of erroneous tasks that can lead
Available online 24 December 2014
to patient radiological overexposures. The results allow for the identification of human errors that are
Keywords: necessary to achieve a better understanding of health hazards in the radiotherapy treatment process, so
HDR brachytherapy that it can be properly monitored and appropriately managed.
Human errors & 2014 Elsevier Ltd. All rights reserved.
THERP
HEART
Fuzzy
http://dx.doi.org/10.1016/j.radphyschem.2014.12.012
0969-806X/& 2014 Elsevier Ltd. All rights reserved.
F. Castiglia et al. / Radiation Physics and Chemistry 116 (2015) 262–266 263
radiotherapy treatment process so that it can be properly mon- HEP relevant to each subtask is the THERP handbook (Humphreys,
itored and appropriately managed. Therefore, the method seems 1995). The HEP entered into the tree is modified by assessor using
able to improve the safety and quality of processes where failure the Performance Shaping Factors (PSFs), which consider the
modes and human factors are the most important causes of acci- training or stress level and other factors that may influence the
dental events. task fault.
The probability that an error will occur is given by Pi, the joint
probability that an error will occur and that the error will lead to
2. Human error evaluation methodologies
system failure is given by (PSFi Pi), the probability that an opera-
tion will be performed and that does not lead to system failure is
In large and complex industrial systems, the human error has
been cited as a cause or contributing factor in a lot of disasters and given by (1 PSFi Pi). The probability that a class of errors will lead
accidents. Thus the need for improved Human Reliability Analysis to system failure is given by Σi PSFi Pi
(HRA) methodologies for application to Probabilistic Safety As-
sessments (PSA) has motivated a number of major activities in
research and development worldwide, at since early 1990s. 2.2. Fuzzy HEART technique
As well known, the first generation approaches in Human Re-
liability Analysis tend to break a task into component parts and The HEART technique assumes that any predicted reliability of
then consider the potential impact of modifying factors such as task performance may be modified according to the presence of
time pressure, equipment design and stress. By combining these the identified EPCs. The method identifies nine generic task types
elements a nominal Human Error Potential (HEP) is determined. and proposes nominal human unreliability values, in addition to
The HEP can be modified taking into account the context-related 17 EPCs whose influence on task performance is considered to
Performance Shaping Factors (PSFs) which consider the state and have a maximum effect.
importance of various factors that will determine the task per- The failure rate is estimated by using the empirical expression
formance. This classification includes tools like HEART and THERP
techniques. ⎧ ⎫
P=P0⎨ ∏ ⎡⎣(EPCi − 1)Api + 1⎤⎦⎬
⎪ ⎪
⎪ ⎪
⎩ i ⎭ (3)
2.1. THERP technique
where P is the probability of human error, P0 is the nominal
THERP technique, developed in the Sandia Laboratories for the human unreliability, EPCi is the ith error-promoting condition and
US Nuclear Regulatory Commission, is the well-known tool based Api is the engineer's assessment of the proportion effect (from 0
on event-tree approach for evaluating the probability of a human to 1) for each ith EPC (Castiglia et al., 2010).
error, in a similar way to an engineering risk assessment (Swain, Castiglia et al. (2010) proposed to modify the technique by
1964; Swain and Guttman, 1983). In this method, the individual is
using the concept of fuzzy linguistic expressions in the re-
treated in a manner similar to technical components and the re-
presentation of the proportion assessment factor, Api. This ap-
sultant tree portrays step by step of the stages involved in a task,
proach is taken because in the HEART model this parameter is the
in a logical order.
An example is provided in Fig. 1 where capital letter “A” re- one most characterized as subjective and imprecise.
presents the fact that the technician has incorrectly performed a The concept of the linguistic variable (LV), consisting in a
task with probability P(A); the lower case letter “a” represents the variable with values defined as words, phrases or sentences in a
fact that this task has been correctly performed and the prob- natural or artificial language, is very useful when one deals with
ability is P(a)¼1 P(A). situations too complex or ill-defined to be reasonably described in
The following relationship should also be required: conventional quantitative expressions. These linguistic values can
P(a)P(b|a) + P(a)P(B|a) + P(A)P(b|A) + P(A)P(B|A) = 1.0 be represented by the approximate reasoning of fuzzy numbers.
(1)
For example, for Very Low (VL), Low (L), Medium (M), High
The HEP that the operator will unsuccessfully complete the task (H) and Very High (VH), the fuzzy number of these linguistic va-
is a complex conditional probability involving much possible lues can be described as reported in (Castiglia et al., 2010). The
combinations of errors, however if these errors just happen to be linguistic variables, so represented, can be used to estimate the Api
independent the conditional probabilities are just the same as the
and Eq. (3) is written as follows:
simple ones and the failure probability can be calculates as fol-
lows: P(x)=P0 ∏i ⎡⎣(EPCi − 1)Ap LVi (x) − 1⎤⎦ with
P(F) = P(a)P(B|a) + P(A)P(b|A) + P(A)P(B|A) LV = VL, L, M, H,VH (4)
= P(a)P(B) + P(A)P(b) + P(A)P(B) (2)
where ApLVi is the fuzzy proportion assessment factor as reported
The primary source of guidance for the quantification of the in (Castiglia et al., 2010).
Fuzzy linguist variable, ApLVi Triangular fuzzy probability P(x1; x2; x3)
Compared to some other HRA methodologies, THERP analysis
requires a large amount of effort to produce HEP values (Hum-
phreys, 1995). Moreover, this tool has the range of PSFs considered
generally low and the underlying psychological causes of errors
(0.0015;0.0024;0.0035)
are not identified (Kirwan, 1996, 1997).
To enhance the performance of the THERP method, in this
paper it is proposed that each subtask in the THERP event-tree is
considered independent from all others, so the error probability
can be calculated by using Eq. (4). This approach allow to take into
account the state and importance of various factors that determine
the task performance.
Medium (M)
Medium (M)
Medium (M)
shielded safe and the treatment applicator. The medical team has
Low (VL)
High (H)
High (H)
High (H)
High (H)
High (H)
High (H)
Low (L)
radiation oncologists, medical physicists, and specialty-trained
therapists who work within the treatment preparation area to
simulate and plan treatment. Moreover further physicians work
with the oncologists and medical physicists to design and deliver
EPC17¼ 3
treatment delivery process, check the treatment unit program,
monitor the treatment progress, and review the emergency
procedures.
Use of incorrect basic data (tables, files, radionuclide and source model,
Verification error
B1
C1
E1
Table 2
Fuzzy HEART probabilities in Task2.
Subtask Error description EPC description and value Fuzzy linguist variable, Triangular fuzzy probability P(x1; x2; x3)
ApLVi
A2 Transcription errors of the setup Information overload, EPC8 ¼ 6 Medium (M) (0.0039;0.0101;0.0207)
parameters Transfer knowledge from one task to another, High (H)
EPC10¼ 5
Poor, ambiguous or ill-matched feedback Low (L)
EPC13¼ 4
B2 Incorrect patient identification Ambiguity in the required performance stan- Low (L) (0.0009;0.0026;0.0055)
dard, EPC11 ¼5
Mismatch between perceived and actual risk, Very Low (VL)
EPC12¼4
Poor instruction or procedures, EPC16¼ 3 Medium (M)
C2 Verification error Poor, ambiguous or ill-matched feedback, Medium (M) (0.0015;0.0024;0.0035)
EPC13¼ 4
Little or no independent checking or testing of High (H)
output, EPC17¼ 3
5. Conclusion
Swain, A.D., 1964. THERP, SC-R-64-1338, Sandia National Laboratories, Albu- Kirwan, B., 1996. The validation of three human reliability quantification techniques
querque, NM. – THERP, HEART, JHEDI: part I -technique descriptions and validation issues.
Swain, A.D., Guttman, H.E., 1983. Handbook of Human Reliability Analysis with Appl. Ergon. 27 (6), 359–373.
Emphasis on Nuclear Power Plant Applications. Sandia National Laboratories, Kirwan, B., 1997. The validation of three human reliability quantification techniques
Albuquerque, NM, NUREG/CR-1278, SAND800 200, RX, AN. – THERP, HEART, JHEDI: part II-Results of validation exercise. Appl. Ergon. 28
Human Reliability Assessors Guide: a report by the human factors in reliability (1), 17–25.
group - SRD Association, Warrington (Author) - Humphreys P. (ed.,) - Publisher:
AEA Technology (December 17, 1995).