assessment and management of human errors in emergency situations by hepi method (case study: a manufacturing industry)

human errors are one of the most important causes of accidents. because time limitation is the most effecting factor in human errors, the likelihood of these errors in emergencies’ is higher than normal conditions. this study was aimed to manage and evaluate human errors in a case of fire in a manufacturing company. in this study human error prediction index (hepi) was used in order to evaluate the human errors. the scenario of fire was designed and the relevant maneuver was performed; then the results were studied in detail. data were collected and analyzed in order to calculate the probability of success in 16 required movements from the muster point to the temporary safe shelter. based on the findings of this study, the highest human error risk is allocated to egress phase including, listening and following pa announcements, evaluating potential egress paths and choosing a route and an alternate route if egress path is not tenable. since reducing the risk of human errors can lead to decrease in the consequences of accidents, the findings of this study emphasize the need of identifying emergencies and developing appropriate scenarios, holding emergency response exercises and analyzing them and providing the necessary feedback for the staff.