Summary

Predictive Human Error Analysis in Permit To Work system in a petrochemical plant

Summary

Permit To Work (PTW) is a means of safety system to coordinate different work

activities. However, it may be susceptible for human error. The purpose of this study was
identification and analysis of human errors in PTW system using Predictive Human Error
Analysis (PHEA) technique. The most important identified errors. Human error defined as
any situation in which an operator fails to do an activity within the tolerance of the system
that can result in unacceptable or undesirable result

HTA is a systematic method to describe how work is organized in order to meet the
overall objective of the job. It involves identifying in a top down fashion the overall goal of
task, then various subtasks and the condition under which they should be carried out to
achieve the goal In this study all tasks that were selected as critical and susceptible to human
error consequences were analyzed by HTA method and its information was gathered through
observation method, interviewing with workers and reviewing procedures and documents.

Training: Inadequate training has been found to be one of the failures relating to the
operation of P.T.W system (HSE, 2005). Effective training is essential to achieve quality and
consistency in the use of the permit-to-work system. Some of human errors identified in the
PHEA worksheets, were because of inadequate and shortcomings in training programs.
Therefore, training needs in P.T.W system were determined specifically for each task in
PHEA worksheets

Work procedures: Studies have showed that 11 to 24% industrial accidents occurred
due to lack and weaknesses related in procedures (Peterson 1996). Rasmussen’s classified
these errors as rule based errors (Kirwan 1997). In this study, some of human errors identified
in the PHEA worksheets, were because of shortcomings in