Int J Syst Assur Eng Manag
https://doi.org/10.1007/s13198-021-01141-8
ORIGINAL ARTICLE
Modification of the FFTA method for calculating and analyzing
the human reliability of maintenance groups in power
transmission grids
Mehdi Tavakoli1 • Mehdi Nafar1
Received: 13 August 2019 / Revised: 16 April 2021 / Accepted: 22 May 2021
 The Society for Reliability Engineering, Quality and Operations Management (SREQOM), India and The Division of Operation and
Maintenance, Lulea University of Technology, Sweden 2021
Abstract The probability of the correct performance of the
activities required by the system over a given period of
time and the working conditions specified by a person is
called human reliability. Human reliability is seen in all
industries, and it can affect the performance of the system
or results in unpleasant events. In electrical power systems,
the human errors of maintenance groups are one of the
most important factors in the failure of electrical equip-
ment. In this paper, a new method based on the combina-
tion of Fault Tree Analysis (FTA) and Human Factors
Analysis and Classification System is presented in order to
calculate and analyze the human reliability in electrical
power systems. In this method, the basic causes (roots) of
human errors are comprehensively identified in all aspects.
The relationship among the causing roots, and also between
the human errors and these roots are established logically.
Finally, human reliability can calculate easily. Since the
data available in this study are mostly linguistic, the fuzzy
logic is used to eliminate the inaccuracy of the evaluation
and to improve the FTA technique. The validity and the
accuracy of the presented method are assessed by the
results of human reliability analysis in Fars Electricity
Maintenance Contractor Company as a case study. Results
show the accuracy of the proposed method for human
reliability analyses of maintenance groups in power trans-
mission grids.
& Mehdi Nafar
mnafar@miau.ac.ir
Mehdi Tavakoli
mehditavakoli@miau.ac.ir
1 comprehensive studies to consider all affecting aspects of
Department of Electrical Engineering, Marvdasht Branch,
Islamic Azad University, Marvdasht, Iran
Keywords Human reliability  Power transmission 
Maintenance groups  Fault tree analysis
1 Introduction
The electric power industry is one of the most influential
industries in present human life. Electrical energy supply to
the customers starts from energy production level and
transmitted by transmission grids and finally supplied by
distribution network to the customers. A large number of
customers may experience unplanned outages (automatic)
due to failure of transmission equipment. Several factors
lead to the automatic outages of transmission lines and
substations. Some of these factors have been expressed in
Veloza and Santamaria (2016) by analyzing fourteen major
power system blackouts across the world between 2003 and
2015. One of these factors is human errors during the
maintenance process. NERC studies show that in North
America automatic outages, human error is one of the four
most important causes of outages (Ekisheva et al. 2016).
Human error occurs in all industries and can affect the
performance of the system or results in unpleasant events
(DeMott 2016). The probability of the correct performance
of the activities required by the system over a given period
and the working conditions specified by a person is called
human reliability (Tang et al. 2013). Research on Human
Reliability Analysis (HRA) has begun almost from the
1950s and developed intensively in nuclear power plants,
aerospace, and other industries with high safety needs
(Tang et al. 2013). However, in the electrical industry
research on this concept is not fully carried out and needs
human reliability. This matter is more important in the
123

maintenance actives in the electric network. The electrical
maintenance activities involve different kinds of activity
which are different from other industries such as nuclear,
for example working in a High Voltage environment,
working in various climates (Gupta et al. 2013), variety of
equipment, etc.
In (Lu et al. 2013), a suitable method for quantitative
assessment of human reliability is presented. However, in
the proposed method, organizational factors and inter-de-
pendency between operators in power system switching
operations are not considered (Tang et al. 2013; Bao et al.
2013). In order to improve the method in Lu et al. (2013),
references (Tang et al. 2013) and (Bao et al. 2013) suggest
ways to measure and analyze human reliability in the
power system, taking into account organizational factors
and the interdependency between operators during the
switching operations. The results of references (Tang et al.
2013) and (Bao et al. 2013) indicate that the probability of
human error is closer to the actual situation recorded in
statistics than (Lu et al. 2013). (Peng-cheng et al. 2012)
also presents a model for describing the impact of orga-
nizational factors on the human reliability of the mainte-
nance groups at the nuclear power plant. The result of this
assessment shows that the effect of factors such as
‘‘inadequate available time‘‘ and ’’inadequate training‘‘ are
high on human error, but factors such as ’’task design‘‘ and
’’operation procedure‘‘ have the least effect. Human relia-
bility analysis is done in Bao et al. (2018) for various
power system scenarios. Results show that the probability
of human error increases when the time of work extends to
more than ten hours per day. During switching operations,
’’experience‘‘ and ’’adequate available time‘‘ affect the
operator’s performance. With regard to the above-men-
tioned researches, some issues need to be followed:
(1) Although human reliability analysis is very impor-
tant, most researches in the power system only
examine technical errors and neglect the impact of
human factors in this concept (Bao et al. 2014).
(2) Most researches on HRA are done on other industries
which are not completely adaptable to power system
(Bao et al. 2018). (Peng-cheng et al. 2012) and (Bao
et al. 2014) explain that the available methods in the
HRA have drawbacks to be implemented in the
power system.
(3) The roots of human error identified in the previous
studies have focused mainly on human performance,
such as stress, working conditions, etc. (Bao et al.
2014). However, in order to have an accurate
assessment of human reliability, it is necessary to
identify the roots of human errors comprehensively
in all aspects at first.
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Int J Syst Assur Eng Manag
(4) Most of the studies were based on the operator’s
mistakes during the switching process. While the
analysis of the events of 2013 to 2018 in the Fars
Electricity Maintenance Contractor Company
(FEMCC) indicated that the maintenance personnel
errors were 406% higher than the operators.
(5) During maintenance operations, the supervisor mon-
itors the operation of the maintenance which is an
important issue for the assessment of the correct
operation of the executive groups. The impact of this
issue on the HR of executive teams has not been
considered in previous studies.
According to these issues, the purpose of this paper is to
calculate and analyze the human reliability of the power
transmission grids maintenance groups to cover the above-
mentioned fact in HRA. In this paper, the Modified Fuzzy
Fault Tree Analysis (MFFTA) method is used for the
evaluation of HR and analysis. The FTA method is used to
evaluate the causes that lead to system failure (Benabid
et al. 2018). The FTA is a quantitative evaluation technique
that identifies an event as the top event and systematically
arranges all the causes of the error in a top-down structure
that looks like a tree in order to, calculate the probability of
occurrence of the top event (Jaise et al. 2013). The FTA is
used to predict power system reliability in different
researches (Benabid et al. 2018; Jaise et al. 2013; Rane and
Narvel 2016). In this paper, in order to improve the
implementation of the FTA method, all aspects of the error
roots were identified using the Human Factors Analysis and
Classification System (HFACS) model which is well suited
for identifying the roots of human factors compared to
other methods. With the help of the HFACS model, all
causes of human error can be identified from all aspects in
19 causal groups at four levels of unsafe acts, precondition
for unsafe acts, unsafe supervision, and organizational
influence (Dekker 2002; Daramola 2014). Advantages of
the proposed method are its simplicity comprehensibility,
the ability to identify the roots of the error completely and
comprehensively, a simple calculation of HR, determina-
tion of the relationships between the roots of the errors, and
the impact of each of them on the human error at a glance.
This study helps managers to design and implement cor-
rective and effective actions to reduce human error by
providing a comprehensive view of the potential causes of
human error.
The paper is organized as follows Sect. 2 explains the
research methodology. Section 3, using the HFACS tech-
nique, most of the root causes of human errors of mainte-
nance groups are predicted. Then in Sect. 4, the
relationship between the causes is modeled using the fault
tree technique. In Sect. 5, the model presented with fuzzy
logic is quantified. The probability of human reliability of
Int J Syst Assur Eng Manag

the FEMCC maintenance groups is calculated in Sect. 6. In
Sect. 7, effective and critical roots must be identified and
prioritized due to resource constraints. Corrective measures
to improve human reliability by analyzing critical roots are
suggested in Sect. 8.
(2)
2 Methodology
To calculate, analyze and improve the human reliability of
FEMCC maintenance groups, research has been done
according to the algorithm of Fig. 1. The steps defined in
the algorithm are as follows:
(1) The first step in the HRA is to identify the causes of
human errors and their classification to reduce or
eliminate these errors (DeMott 2016). However,
(3)
comprehensive studies and research have not been
carried out to identify most of the causes of human
error in the power transmission industry and to
evaluate human reliability (HR). In this paper, a
comprehensive library study was conducted to iden-
tify the root causes of errors in maintenance groups,
which revealed that the HFACS model is well suited
to all the methods for identifying the root causes of
human factors in events. Thus, a complete bank of
human error roots in the transmission power main-
tenance groups is predicted and collected with the
help of experts’ knowledge in 19 causal groups at
four levels of the HFACS model.
Since there is no documentary information from the
history of past events, especially about the basic
causes of errors, calculating the probability of
occurrence of human error roots is not possible
simply. Therefore, a survey of experts is done by the
questionnaire, and the probability of occurrence of
the event is calculated. Then the use of knowledge
and judgment of experts, given that expert individ-
uals have sufficient knowledge of the subject matter,
can be very helpful to evaluate the probability of an
occurred error.
The FTA method has been used to establish a logical
relationship between causes and ultimately find the
probability of a human error occurring. The Fault
Tree Analysis (FTA) method was first used by Bell
Telephone Laboratories in the evaluation of the
reliability of the ballistic missile launch control
system in the years 1961–62 (Jaise, et al. 2013). The
top event is the unwanted event that is the subject of

Human Reliability Calculation HFACS M odel

Identifying human error Task analysis

Summarizing
roots in maintenance
on four levels
groups
of error
(1)

Human Reliability Analysis

Event records analysis
(5)

Predicting the
Taking steps to reduce
probability of the roots the method of
or eliminate critical
occurrence experts survey
roots
(2) Interview with experts

Analysis and
Relationship between Review past articles
evaluation of root
roots and human error
effects on the FTA method
with roots
probability of human
(3)
error occurrence

Calculating the
probability of human Trapezoidal
Prioritization of roots
error in maintenance Fuzzy Logic
to identify critical roots
groups Technique
(4)

Fig. 1 Algorithm for calculating, analyzing, and improving the reliability of the maintenance groups used in this research

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the FTA. The causes of the top event occurrence are
the Intermediate events that their relation with the
top event is connected by logically. Intermediate
events are also connected logically to the causes of
their occurrence, the basic events.
(4) The fuzzy logic method has been used to calculate
the probability of human error due to the ambiguous,
qualitative, and subjective use of experts’ knowledge
in estimating the probability of occurrence of the
roots of the error. Fuzzy logic in encountering and
evaluating incorrect and ambiguous situations pro-
vides opportunities that embody the power of
creativity and human perception of ambiguous
concepts.
(5) After calculating the probability of human error, the
effect of roots on the probability of human error
occurrence is analyzed and evaluated. In the end,
solutions will be proposed to eliminate more effec-
tive causes. Again, the probability of the occurrence
of the error roots is estimated, and the cycle shown in
Fig. 1 is repeated to the point where the reliability of
the human being improves.
3 Identification of the root causes of human error
in maintenance groups
The maintenance process is one of the important processes
in the operation of power grids. If the maintenance is done
suitably it can reduce the power outages and interruptions.
Maintenance is a set of scheduling, preparation of spare
parts, implementation, monitoring, and management
activities to maintain or repair the system in a manner that
performs the expected performance throughout the system
life cycle. An error in the planning, implementation, or
monitoring of maintenance operations can lead to system
failure and, consequently, interruption of customer
services.
At the beginning of this research, all maintenance
groups in FEMCC were investigated in terms of tasks and
activities. The results of these surveys showed that line,
substation, and protection groups carry activities with high
human error rates relative to the rest of the working groups
in maintenance units. To identify and predict the causes of
human error in these groups, the following pattern was
implemented in the framework of the HFACS model:
• Collecting the results of studying researches on human
errors, especially in the field of maintenance
• Reviewing the steps of maintenance implementation
• Investigating the records of power transmission indus-
try events due to human error
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Int J Syst Assur Eng Manag
• Interviewing the FEMCC maintenance experts and
technicians who had made a mistake
• Interviewing FEMCC skilled staffs in the maintenance
groups
• Interviewing FEMCC expert supervisors on mainte-
nance personnel
• Interviewing the FEMCC safety experts
• Conclusion of the information and opinions related to
the previous sections in order to design of the
questionnaire for human error description in power
system through the HFACS framework
• Selecting a population and Survey their opinion again
by the previous questionnaire
• Finalizing the basic causes of human errors at the four
levels of errors in the HFACS method according to
Table 1.
4 Fault tree analysis of the identified causes
To construct a fault tree diagram, it’s necessary to deter-
mine the top events, the intermediate events, and the base
event, and then establish the cause and effect relationship
between these events using logical gates.
In this study, the top event is the human error of the
maintenance groups. The intermediate events were identi-
fied as a failure to study the protection diagrams before the
maintenance, failure to follow the instructions, careless-
ness, lack of expertise or sufficient experience, and the
impact of the supervisor. According to expert opinion, each
of the intermediate events alone can cause the top event to
occur. Therefore, the relationship between the intermediate
events with the top event can be implemented by ’’OR‘‘
logic. Basic events are linked to intermediate events
according to the information gathered in the previous
section. It is worth noting, that some of the basic causes
identified in the preceding section are due to the occurrence
of some other basic causes. Therefore they are considered
as an intermediate event. The relationship between the
intermediate and basic events is established with the ’’OR‘‘
logic by examining. After construction of the fault tree
diagram based on experts’ opinions and studies of the
previous section, the tree is again evaluated by the experts
to confirm its accuracy. The final fault tree is shown in
Fig. 2. Table 2 expresses the codes of the intermediate
events and the basic events displayed in the fault tree.
Int J Syst Assur Eng Manag

Table 1 The number of basic causes of human error at the levels of the HFACS method
Error level Error category Error subcategory Number of basic causes of error

Unsafe acts Errors Skill based error 1

Decision error 5
Perceptual error
Violations Routine violation 2
Exceptional violation 1
Preconditions for unsafe Operator conditions Adverse mental state 5
acts Adverse physiological state 1
Physical/mental limitations
Individual factors Communication coordination and 4
planning
Fitness for duty
Environmental factors Physical environment 1
Technological environment
Unsafe supervision Inadequate supervision 4
Planned inappropriate operations 9
Failed to correct a known problem 1
Supervisory violation 2
Organizational influences Resource management human resources 2
Funds 3
Equipment resources/facilities 3
Organizational climate Structure 4
Culture 1
Politics 3
Organizational process operation 2
methods 3

5 Determination of the basic events occurrence
probability
Since there is no technical and reliable data to determine
the probability of basic events, experts’ opinions are used
to calculate this probability in this study. Since experts
cannot estimate the probability of an event exactly. The
fuzzy logic is utilized to express the expert judgment using
linguistic terms (very low, low, moderate, high, and very
high). The fuzzy logic for calculation of the probability of
the top and intermediate events is implemented in 5 steps
as follows:
competence due to different criteria such as age, education,
experience, organizational title, etc. For this reason, the
method presented in Renjith et al. (2010) is used to
determine the importance weight of these experts. Table 4
shows the criteria of the importance of experts along with
the corresponding scores for them. The relative weight of
each expert is achieved from the division of the total scores
of each expert into the total score obtained by all the
participating experts in the study (Rajakarunakaran et al.
2015). This is expressed in Eq. 1.
P4
Ski
WK ¼ P10 i¼1 P4 ð1Þ
j¼1 i¼1 Sji

5.1 Determination of technical evaluation of experts where WK is the relative weight of the expert k, Ski is the
score of the expert k on four criteria, Sji is the score of the
Based on criteria such as experience, expertise, etc. 10 expert j on four criteria, i is the number of criteria for
experts are selected for expressing their judgments about ranking experts and j is the number of experts.
the probability of occurrence of basic events. Table 3
shows the opinions of these experts from FEMCC in
relation to basic events. These experts do not have the same

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 Int J Syst Assur Eng Manag

BE
IE TE
Organizational influences Unsafe supervision Preconditions for unsafe acts Unsafe acts

O6
O3 IS6

O4
IU3
IP2
IO1
O13

IP8 IE1
O10

IU1 Human error

O2 of
IP7
O14 maintenance
IP6
groups

O12 O18
S7 P11
IE3

O19 IS5
O15
IP3

IP9
U2 IE4
O20
P4

IU5

IP10
O11
IE5

IU6 IU4
IU
O2

IE6
IO8 IS9
IP5

S2

S8
S11

BE
IE TE
Organizational influences Unsafe supervision Preconditions for unsafe acts Unsafe acts

IE1

S14

S13
IE2

O17
P1
IE3
Human error
O9 of
maintenance
groups

S1
O7
IE4

O5 IO8

O20 IU9
IS12

IU8
O16

IE5

O14

O2

O21
IE6
S10

S2

S15

S16

S11 IS3

S4

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 Int J Syst Assur Eng Manag
b Fig. 2 Schematics of fault tree of the top event (maintenance human
error)
5.2 Conversion of expert’s judgment into fuzzy
numbers
Since experts’ judgments are described qualitatively, the
method presented by Chen, Hwang in 1992 (Renjith et al.
2010) is used to systematically convert linguistic expres-
sions to their corresponding fuzzy numbers. In this paper, 5
linguistic expressions (very low, low, medium, high, and
very high) are fuzzified using the membership function
shown in Fig. 3. Therefore each comment is expressed in
the form of a trapezoidal fuzzy numberMi ¼ ðm1 ; m2 ;
m3 ; m4 Þ.
5.3 Aggregating fuzzy numbers all of experts
judgment related to any event
Because experts’ opinions differ on the probability of
occurrence of the basic events. Therefore, there should
aggregate different opinions and convert them to a single
one. Aggregating of experts judgment due to the avail-
ability of the relative weight of the experts and the fuzzy
number of each expert’s linguistic expressions are obtained
with the help of Eq. 2 (Renjith et al. 2010).
X
10
Ai ¼ Wj mij
j¼1
where Ai is fuzzy numbers summation of experts opinion
on the basic event i, mij is the opinion of the expert j about
the basic event i and wj is the average relative weight of the
expert j.
5.4 Defuzzifying of aggregated opinions
At this step, fuzzy numbers summation of experts’ opin-
ions, which are called the aggregated fuzzy failure possi-
bility (AFFP), should be converted into a crisp score under
the title of the crisp failure possibility (CFP). In this paper,
the center of gravity method is chosen for defuzzification.
The defuzzification of Ai ¼ ða1 ; a2 ; a3 ; a4 Þ is obtained using
Eq. (3) (Lavasani et al. 2015).
ða4 þ a3 Þ2  a4 a3 þ a1 a2  ða1 þ a2 Þ2
CPSi ¼ 1=3 
ða 4 þ a 3  a 1  a 2 Þ
where CPSi is a crisp possibility score for the basic event i.
5.5 Converting CPS of the basic events
into probability
The last step of the fuzzy approach is to convert CPS of
basic events to the failure probability of the event using the
Onisawa relationship (Eq. 4)(Renjith et al. 2010; Rajakar-
unakaran et al. 2015; Lavasani et al. 2015.
(
1
FPi ¼ 10k CPSi 6¼ 0 ð4Þ
0CPSi ¼ 0
1  CPSi 1
k ¼ 2:301  ð Þ =3
CPSi
where FPi is failure probability of the basic event i.
Table 5 shows the results of quantifying experts’ opin-
ions regarding the probability of base events in Table 3 in
accordance with parts 4.2 to 4.5.
6 Determining the failure probability of the top
event
The FP of the top event (the human error of the mainte-
nance groups) can be calculated through the probability of
a minimal cut set.
A cut set (CS) is a set of one or more basic events that if
they occur together, the top event will occur. The minimal
cut set (MCS) is a CS that does not have any further
ð2Þ simplification. Identifying MCSs and calculating their
probabilities (Eq. 5 (Renjith et al. 2010)) is important.
Because, with the help of them, the failure probability of
the top event can be calculated by Eq. 6.
  Yn
P MCSj ¼ FPi ð5Þ
i¼1
Y
K
PTE ¼ 1  ð1  PðMCSj Þ ð6Þ
J¼1
 
In the above equations, P MCSj represents the proba-
bility of MCS of j, n is the number of basic events per
MCS, k is the number of identified MCS and PTE indicates
the failure probability of the top event (Rajakarunakaran
et al. 2015).
In this research, with regard to the constructed error tree,
the identified MCSs are similar to the basic events, because
all the relationships between the top events and the basic
ð3Þ
events are through the ‘‘OR’’ gates. Therefore, the proba-
bility of MCSs is the same as the probability of basic
events. The probability of human error occurrence of
maintenance groups according to experts’ opinions and the
Eq. 6 is calculated to be 0.0056, which according to this
value, the human reliability of FEMCC maintenance
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Table 2 Intermediate and basic events codes in Fig. 2

Event Causes of the error Event Causes of the error
code code

IE1 Carelessness S7 Highly demanding maintenance operations and accompanied

by repetitive actions
IE2 Lack of protection diagrams S8 Tracking to fix mistakes related to the existing data, settings,
spare parts, etc. by executive teams at runtime
IE3 Failure to study the protection diagrams before the IS9 Longer maintenance time of more than 8 h
maintenance
IE4 Failure to follow the instructions S10 The employer’s request for the operation of the maintenance
outside the rules or guidelines
IE5 Lack of expertise or sufficient experience S11 The synchronization of corrective or defective projects with
maintenance operation
IE6 The impact of the employer IS12 Unsuitable appointment of personnel for sensitive tasks
IU1 Hurry up in work S13 Repeat the actions
U2 Mobile answering during work S14 Lack of follow-up for the fixing of defects by the supervisor
IU3 Personnel are sometimes not ready for maintenance for any S15 The supervisor’s work announcement out of the maintenance
reason program
IU4 Do not check some checklist items S16 Inappropriate respect for the personnel
IU5 The instructions and setting have not been revised and the IO1 There is no proper motive
mistakes have been repeated several times
IU6 The existence of viewpoints that some checklist items are O2 Lack of proper specialized training
important and should be checked and the rest is not needed
IU7 Insufficient knowledge of the cause and performance of each O3 Insufficient salary
item in the checklist or settings
IU8 Tasks are more than a person’s ability O4 There is not much difference between personnel with and
without responsibility
IU9 Choosing the wrong method for maintenance O5 Lack of budget to provide new or updates for the grid
equipment
P1 Pride for various reasons, including experience, age, specialty, O6 Development in power grids
…
IP2 Psychasthenia O7 Complex and varied electrical network equipment
IP3 Lack of paying attention to the family and time spent on them, IO8 Lack of sufficient and up-to-date equipment
which can be a source of discomfort and fatigue for the staff
P4 The misconception is that increasing the workload grows the O9 Information, instructions, results of meetings, etc. from the
probability of a human error directors or heads of departments to the personnel are not
properly transmitted
IP5 Impatience of groups O10 The personnel promotion manual is not transparent and
appropriate
IP6 Physical tiredness O11 Lack of proper communication between the subgroups and
feedback from each other
IP7 Lack of backup technician O12 Transmission of stresses and work collisions from upstream
to downstream
IP8 Having a second task O13 Lack of financial and mental attention of the organization to
personnel
IP9 Continuous missions abroad O14 There is no specific policy for empowering and trusting
personnel with less experienced
IP10 Not paying attention to the mistakes expressed in previous O15 Delays in employing expert personnel
operations and corrections by the relevant subgroups
P11 Not suitable environmental conditions (heat, cold, weather, O16 Not enough attention is paid to employment factors based on
etc.) that can affect the performance of the person merit and professional qualifications
S1 Inappropriate knowledge of equipment instruction due to lack O17 Lack of test instructions
of proper transfer of prior experience
S2 Limited knowledge or experience of the supervisor O18 Job description and organizational structure are not complete
IS3 The supervisor emphasizes the full implementation of the O19 lack of clear instructions for punishment and encouragement
maintenance operation without prioritizing tasks

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Table 2 continued
Event Causes of the error Event Causes of the error
code code

S4 Employer or supervisor having the view that the appearance O20 Inappropriate planning to use all staff and facilities
and cleanliness of the work are less important than the
correct performance of the equipment
IS5 Maintenance personnel does not have the proper time to rest O21 lack of exact analysis of the human errors event
and upgrade their knowledge
IS6 Doing the maintenance operation at an inappropriate time
(such as: from 0 am to 6 am or holidays)

Table 3 The opinions of experts in relation to basic events

Basic event code Expert 1 Expert 2 Expert 3 Expert 4 Expert 5 Expert 6 Expert 7 Expert 8 Expert 9 Expert 10

U2 H L L L L H L H VL M
P1 L L L M M M VL M M VL
P4 H M H VH L VH L M M H
P11 H L H H L M L L M M
S1 L M L VL L H VL L VL L
S2 L M L L M H M L M M
S4 M H M M M M H M L M
S7 L L L L M VH L M M M
S8 M H L H L H M M M M
S10 L L L L VH VH M L VL M
S11 L VH L L H VH M M L M
S13 H H M H L L H M M M
S14 H M H H L VH L H L H
S15 L M L M L L M M L L
S16 VL M L H L M M M L L
O2 M H H L M VH L M M H
O3 L M VL M L VH H H M H
O4 L H M L M H H H M L
O5 L VH M M M VH L M L H
O6 M M M L H L L M M M
O7 VH L L H M H L M M L
O9 L M M M M H L L L L
O10 L M L H M VH VH M M H
O11 L VH H L M L L M M H
O12 M M L M H VH L H L M
O13 L H H L VL VH VH L L H
O14 L H L H M H H M M M
O15 H H L M H VH H M L H
O16 L M H H M VH VL L L M
O17 L M L L L H VL L M L
O18 L H H VH H H L M L L
O19 L VH L L L H H M M M
O20 L H L M M VH L L M M
O21 L VH L M H H M M M H

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Table 4 Scoring criteria for experts 7 Determining the importance and ranking
Constitution Criteria Score of the basic events

Title Manager 5 Corrective action should be taken to improve HR. How-

Chief of group 4 ever, due to the limited resources, corrective actions on the
Chief of subgroup 3 causes that would have a greater impact on the reduction of
Expert 2 the main event (human error) should be considered. In this
Workman 1 study, the MCS importance method is used to determine
Experience (Years) Greater than 20 5 the importance of basic events and their classification.
15–20 4 Minimal cut sets are the shortest paths that the top event
10–15 3 is achieved through the basic events. Therefore, their
5–10 2 analysis can help a deep understanding of the researchers in
Less than 5 1 relation to the importance of each of the possible routes of
Educational qualification Ph.D 5 occurrence of the top event. The importance measure of
M. Eng 4 MCSs is calculated using Eq. 7 (Rajakarunakaran et al.
B.Eng 3 2015).
Electrical technician 2
 
  P MCSj
Secondary school 1 IM MCSj ¼ ð7Þ
PðTEÞ
Age Greater than 45 4  
35–45 3 where IM MCSj is importance measure of MCSj.
25–35 2 Table 6 shows the importance measure of MCSs
20–25 1 according to their classification. Given that each MCS is
expressed by a basic event, therefore the basic event can be
ranked according to the MCS classification, according to
Table 6.
Figure 4 shows how the reliability of the maintenance
groups is obtained 0.9946. On the other hand, the events groups improves relative to the human reliability calculated
caused by the maintenance groups’ error were 33 of 3359 in Sect. 6 if basic events in the order in Table 6 are
workdays of groups at the FEMCC grid within 2018 which eliminated. For example, Four of the most critical MCSs
is led to the human error probability of 0.0049. Therefore, are respectively: delays in employing expert personnel, the
Compared with the statistical data, it is obvious that con- misconception is that increasing the workload grows the
sidering the effect of supervisor on the maintenance per- probability of a human error, lack of follow-up for the
formance using the proposed method can reach an estimate fixing of defects by the supervisor and the personnel pro-
of the human error probability close to the actual value motion manual is not clear and appropriate. If these causes
which is also far higher than the average probability are eliminated, about 20% of the human reliability of
(\ 1%) provided by State Electricity Regulatory Com- FEMCC maintenance groups will improve. Also, if 11
mission (Bao et al. 2013). basic events are removed, it will increase the human reli-
ability from 0.9944 to 0.9973. That is, human reliability
can be increased up to 50% by making corrections in 32%
of the basic events.

Fig. 3 The weight of expert Very low Low Medium High Very high
linguistic expressions in fuzzy
logic

0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

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Table 5 The probability of

Basic event code a1 a2 a3 a4 CFP FP
basic events
U2 0.10091 0.15244 0.15579 0.21067 0.15522 0.00009
P1 0.06707 0.12119 0.12790 0.18872 0.12672 0.00004
P4 0.16372 0.22058 0.22790 0.27744 0.22187 0.00032
P11 0.10122 0.15473 0.15473 0.20823 0.15473 0.00009
S1 0.05427 0.09604 0.10610 0.15793 0.10427 0.00002
S2 0.09238 0.15625 0.15625 0.22012 0.15625 0.00009
S4 0.12500 0.19284 0.19284 0.26067 0.19284 0.00020
S7 0.09360 0.15381 0.15777 0.21402 0.15449 0.00009
S8 0.12957 0.19360 0.19360 0.25762 0.19360 0.00020
S10 0.10213 0.15137 0.16265 0.20732 0.15556 0.00009
S11 0.13323 0.18948 0.19741 0.24573 0.19089 0.00019
S13 0.13872 0.20046 0.20046 0.26220 0.20046 0.00022
S14 0.16220 0.21707 0.22104 0.27195 0.21776 0.00030
S15 0.06585 0.12805 0.12805 0.19024 0.12805 0.00004
S16 0.07957 0.13567 0.13994 0.20030 0.13920 0.00006
O2 0.14726 0.20793 0.21189 0.26860 0.20861 0.00026
O3 0.13598 0.18963 0.19665 0.24939 0.19284 0.00020
O4 0.13354 0.19360 0.19360 0.25366 0.19360 0.00020
O5 0.13750 0.19558 0.20351 0.25366 0.19698 0.00021
O6 0.10030 0.16616 0.16616 0.23201 0.16616 0.00011
O7 0.12561 0.18399 0.18826 0.24238 0.18473 0.00017
O9 0.08506 0.14710 0.14710 0.20915 0.14710 0.00007
O10 0.15183 0.21067 0.21799 0.26951 0.21196 0.00027
O11 0.11890 0.17744 0.18140 0.23598 0.17812 0.00015
O12 0.13384 0.19421 0.19817 0.25457 0.19489 0.00020
O13 0.13567 0.18095 0.19223 0.23415 0.18552 0.00017
O14 0.13902 0.20122 0.20122 0.26341 0.20122 0.00023
O15 0.17348 0.23003 0.23399 0.28659 0.23071 0.00037
O16 0.11555 0.16905 0.17637 0.22927 0.17252 0.00013
O17 0.06768 0.12119 0.12454 0.18140 0.12397 0.00004
O18 0.14268 0.19787 0.20122 0.25305 0.19844 0.00022
O19 0.12226 0.18049 0.18445 0.23872 0.18117 0.00016
O20 0.11220 0.17210 0.17607 0.23201 0.17279 0.00013
O21 0.14878 0.20869 0.21265 0.26860 0.20937 0.00026

8 Analyzing and controlling the critical basic
causes
A successful strategy to reduce the human error of main-
tenance groups is the analysis of the important basic causes
of this error. In the previous sections, four critical causes
were identified, two of which relate to the performance of
the organization, one to the mental conditions of the
maintenance-man and one to poor supervisor performance.
By analyzing these critical causes, the weaknesses and
solutions to resolve them were as follows:
1. The most important basic cause from the viewpoint of
the FEMCC maintenance groups is ‘‘delays in employing
expert personnel’’. Because reducing human resources
(due to retirement, death, injury, etc.) and the lack of
timely recruitment of new personnel will put pressure on
existing personnel, which leads to the physical exhaus-
tion and homesick of personnel. Investigating the causes
of delay in the recruitment of new personnel showed that
the main factor is the time-consuming process of
recruitment, at least six months. Therefore, the following
solutions were proposed to eliminate this problem:

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Table 6 The importance

MCS Relevant basic events IM(MCS) MCS Relevant basic events IM(MCS)
measure of MCSs along with
their classification 1 O15 0.066 18 O7 0.030
2 P4 0.057 19 O19 0.028
3 S14 0.054 20 O11 0.027
4 O10 0.049 21 O20 0.024
5 O21 0.047 22 O16 0.024
6 O2 0.046 23 O6 0.021
7 O14 0.041 24 S2 0.016
8 S13 0.040 25 S10 0.016
9 O18 0.039 26 U2 0.016
10 O5 0.038 27 P11 0.016
11 O12 0.036 28 S7 0.016
12 S8 0.036 29 O9 0.013
13 O4 0.036 30 S16 0.011
14 O3 0.035 31 S15 0.008
15 S4 0.035 32 P1 0.008
16 S11 0.034 33 O17 0.007
17 O13 0.031 34 S1 0.003

O15
P4100 S1
S14 O17
O10 P1
O21 80 S15 Percentage
O2 60 S16
O14 O9
40
S13 S7
20
Basic event code
O18 P11
0
O5 U2
O12 S10
S8 S2
O4 O6
O3 O16
S4 O20
S11 O11
O13 O19
O7

Fig. 4 The percentage of human error probability when eliminating previous basic events

• Provide recruiting instructions to reduce employment 2. The most dangerous thinking of a maintenance man to
time justify others for the mistakes can be that ‘‘due to the
• Action to recruit staff before retiring existing personnel high workload, there is also a possibility of error’’. This
and train them point of view makes the person do his job imprecisely
• Provide a database of job applicants and does not take responsibility for his mistakes. In order
to reduce the effect of this thinking, the following
suggestions were given:

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• Explain the importance of customers interruption for
maintenance groups
• Considering incentives for personnel without error
3. One of the main problems during the maintenance
operation is the lack of documentation, such as technical
drawings, equipment catalogs, test documents, etc. at the
substation. The supervisor is responsible for document
deficiencies. Therefore he/she must ensure that the doc-
uments are always complete and updated in accordance
with any physical change in the substation.
4. Another root cause is ‘‘the personnel promotion
manual is not transparent and appropriate’’ that it reduces
the motivation of personnel and leads to human error.
The research showed that the organization chart of the
maintenance groups was limited to the expert and the
head of the group. For this reason, there has not been a
comprehensive set of guidelines for organizational
growth. So it was suggested:
• Provide instructions for personnel promotion so that
experts are rated
• Changed organizational structure.
9 Conclusion
In this paper, the human error of maintenance groups of
FEMCC power grids was investigated using a combination
of FFTA and HFACS methods. According to the results,
the following issue can be concluded:
1 The roots of human error in maintenance groups were
identified and predicted based on the research carried out
in the power grids, interviewing and conducting a survey
of experts in the form of four levels of the HFACS
method. The number of basic causes detected at the level
of the unsafe acts is nine, the preconditions for unsafe
acts level is eleven, the level of unsafe supervision is
sixteen, and the level of organizational influences is
twenty-one.
2 Using the fault tree analysis method, a logical
relationship between identified causes and human error
was constructed. Within the 57 roots, 34 roots were
identified as the basic event for the top event (which is a
human error).
3. The results of calculating and analyzing the human
reliability of the maintenance groups at FEMCC using
the proposed method (MFFTA) and considering the
effect of the supervisor on the maintenance performance
reach the human error probability of 0.0056 (12%
difference with the actual human error).
4. The ranking of the basic events (causes) showed that
two critical causes relate to the performance of the
organization, one to the mental condition of the main-
tenance man and one to improper supervisor perfor-
mance. If these causes are eliminated, about 20% of the
human reliability of FEMCC maintenance groups will
improve.
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