شناسایی و ارزیابی خطاهای انسانی منجر به حوادث در یکی از پالایشگاه های گاز با استفاده از روش تجزیه و تحلیل فاکتورهای انسانی و طبقه بندی سیستم

Background: incidents are one of the most important causes of damages in an organization. incidents, rarely, occure of a big mistakes ,they usually occur due to chain of Most minor and less important human or series errors. May each error, Have minor consequences But with combination their effects, sets or systems are moving invariably to the serious consequences and disastrous. Therefore, this study aimed to identify human errors leading to incidents in a gas refineries using Human Factors Analysis and Classification System. Methods: This study is a retrospective study that was performed in a gas refinery. incidents Data of this study be provided from gas refinery, first root causes analysis reports (RCA) of incidents that occurred during the last 8 years was prepared And then were analyzed by using the HFACS model. Results: the maximum error of HFACS viewpoint Related to the first level i.e errors caused by unsafe acts that in the first level was related to the "violations", in the second to the physical environment, in the third level to the inadequate supervision and in the fourth level to the management of resources have a Most repeated in mentioned levels Conclusion: The results of this study showed the causes of accidents and several weaknesses In refineries. It can be helped to reduce human error in the organization by utilization at the same time administrative controls and by creating an appropriate learning environment and raise employee awareness.