Review Article

Investigating the Probability of Human Error in Iranian Industrial Control Rooms: A Systematic Review


Due to the human errors in control rooms with a high socio-economic, we aimed in the present study to investigate the probability of human error in some of the Iranian industrial control rooms. In the current study, the related articles based on keywords were reviewed using Google Scholar, Scopus, Embase, PubMed, Web of Science, Magiran, SID, and IranDoc databases from the years 2010 to 2021. The used search terms were "human error", "human failure", "control room", "industry", "human error assessment", "safety management", "Error analysis"  and "human error probability". A comprehensive article review process was conducted to get the required data. To evaluate the quality of the reviewed articles, the Joanna Briggs Institute (JBI) checklist was used. Out of 22 articles that were qualitative for analysis, 14 articles (63.6%) were related to process industries, and 8 articles (36.4%) were related to other industries. The Cognitive Reliability and Error Analysis Method (CREAM) and the Systematic Human Error Reduction and Prediction Approach (SHERPA) techniques were mostly used compared to the other 10 techniques used in the articles.  In order to identify errors in the process industries’ control rooms, CREAM method, execution failure (31.72%-55%), interpretation failure (18.57%-29.20%), SHERPA method, action errors (48.62%-67.64%), and checking errors (11.61%-31.97%) were the main types of errors identification methods.  Although, in other industries, using the SHERPA method, action errors (38.08%-58.80%), checking errors (29.40%-39.04%), Human HAZOP method, delete errors, and performance errors were the main types of errors identification methods in the control rooms.  The results of studies in control rooms showed that human error had a significant share in the occurrence of accidents. However, we were witnessing less attention among Iranian industries such as rail and nuclear.

1. Ghasemi M, Nasleseraji J, Hoseinabadi S, Zare M. Application of SHERPA to identify and prevent human errors in control units of petrochemical industry. Int J Occup Saf Ergon, 2013. 19(2): 203-209.
2. Habibi E, Gharib S, Mohammadfam I, Rismanchian M. Human error assessment in Isfahan oil refinery's work station operators using systematic human error reduction prediction approach technique. Int J Environ Health Eng, 2013. 2(1): 25.
3. Munn Z, Barker TH, Moola S, Tufanaru C, Stern C, McArthur A, Stephenson M, Aromataris E. Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth, 2020. 18(10): 2127-2133.
4. Briere JB, Bowrin K, Taieb V, Millier A, Toumi M, Coleman C. Meta-analyses using real-world data to generate clinical and epidemiological evidence: a systematic literature review of existing recommendations. Curr Med Res Opin, 2018. 34(12): 2125-2130.
5. Mazloumi A, Ziarani MH. Determining Human Error Global Causes in a Petrochemical Control Room with a Cognitive Analytical Approach-CREAM. Int J Occup Hyg, 2017. 9(4): 223-234.
6. Shokria S. A Cognitive Human Error Analysis with CREAM in Control Room of Petrochemical Industry. Biotech Health Sci, 2017(1): 13-21.
7. Mazloumi A, Hamzeiyan ZM, Dadkhah A, Jahangiri M, Maghsodepor M, Mohadesy P, Ghasemi M. Assessment of human errors in an industrial petrochemical control room using the CREAM method with a cognitive ergonomics approach. J Sch Public Health Inst Public Health Res, 2011, 8(4): 15-30.
8. Karimie S, Mirzaei Aliabadie M, Mohammadfam I. Human errors assessment for board man in a control room of petrochemical industrial companies using the extended CREAM. J Health Field, 2018. 6(1): 28-35.
9. Afshari D, Shirali GA. Predictive Analysis of Cognitive Errors of Control Room Operators: a Case Study in a Petrochemical Industry. Iran J Ergon, 2020. 8(4): 31-49.
10. Ghalenoei M, Asilian H, Mortazavi S, Varmazyar S. Human erroranalysis among petrochemical plant control room operators with human errorassessment and reduction technique. Iran Occup Health, 2009. 6(2): 38-50.
11. Halvani G, Mehrparvar AH, Shamsi F, Rafieenia R, Khani Mouseloo B, Ebrahimi G. Risk assessment of human error among Mohr City, Parsian Gas refinery company control room operators using systematic human error reduction and prediction approach SHERPA in 2016. Occup Med Quarterly J, 2017. 9(3): 32-44.
12. Zaranezhad A, Jabbari M, Keshavarzi M. Identification of the human errors in control room operators by application of HEIST method (case study in an oil company). Iran Occup Health, 2013:11-23.
13. Shirali GA, Nakhaei PM, Jahani F, Shakib M, Mir I. Identification and Evaluation of Human Errors Leading to Incidents in a Gas Refinery using Human Factors Analysis and Classification System. J Occup Hyg Eng, 2018. 4:1-11
14. Pouya AB, Habibi E. Using cream techniques for investigating human error with cognitive ergonomics approach in the control room of cement industry. IJBPAS, 2015. 4(3): 1480-1484.
15. Ghahramani A, Adibhesami A, Mohebbi I. An Application of Cognitive Reliability Error Analysis Method for Identification and Evaluation of Human Errors of Control Room Operators in a Cement Manufacturing Company. J Saf Prom Inj Prev, 2020. 7(4): 183-191.
16. Pouya AB, Hazrati S, Vosoughi M, Mosavianasl Z, Habibi E. Evaluation human error in control room. Pak J Med Health Sci, 2017. 11(4): 1596-600.
17. Nezamodini ZS, Movahedi Z, Kouhnavard B, Mosavianasl Z. Investigation of human error by using THERP method in control room of incoiler department in a pipe manufacturing company. Arch Hyg Sci, 2018. 7(3): 200-207.
18. Nejad NSG, Nasirzadeh N. Human Errors in a Syringe Factory in Urmia Using PHEA. Indian J Sci Tech, 2016. 9(30): 1-6.
19. Jahani F, Nasrabadi M, Alizadeh A. Identification and Evaluation of Human Errors in Control Rooms of the Arya Sasol Polymer Company Using the CREAM Technique. J Occup Hyg Eng, 2017. 4(1): 35-44.
20. Barkhordari A, Halvani G, Mohammadian U, Ghasemi M, Fazli Uchhesar B. Risk assessment of Human error and Provide Corrective Actions in Combined cycle power plant Using Systematic Human error Reduction and Prediction Approach SHERPA Method. J Toloo-E-Behdasht, 2015. 13: 46-56.
21. Shirali GA, Malekzadeh M. Predictive analysis of controllers’ cognitive errors using the TRACEr technique: a case study in an airport control tower. Jundishapur J Health Sci, 2016. 8(2).
22. Nezamodini ZS, Abasi M, Mosavianasl Z, Kouhnavard B. Application of Human Hazop Technique for identifying human error in a Flour Company. Archiv Occup Health, 2018. 2(3): 170-177.
23. Varshosaz K, Zangheneh J, Mobarghaee N, Mousavipour S. Risk Assessment and Management Impacts on Humans in the Control Room, Desalting Unit and Compression Station at Maroon using the Human Hazop Method. Environ Sci, 2016. 13(4): 125-136.
24. Afshari D. Human Error Examination InAncoiler Device Control Room of Ahvaz Pipe Mill by SHERPA and HET methods at Year 1390. Iran Occup Health, 2013. 10(3): 69-77.
25. Li X, McKee D, Horberry T, Powell M. The control room operator: The forgotten element in mineral process control. Miner Eng, 2011. 24(8): 894-902.
26. Babaei Pouya A, Hazrati S, Mosavianasl Z, Habibi E, Systematic Human Error Reduction and Prediction Approach: Case Study in Cement Industry Control Room. J Occup Environ Health, 2017. 2(4): 272-84.
27. Shirali G, Hosseinzadeh T, Dibeh Khosravi A, Rasi H, Moradi MS, Karami E, Fathi A, M Rezaei, Barzegar L. Integration of human information processing model and SHERPA technique in the analysis of human errors: A Case Study in the control room for the petrochemical industry. Iran Occup Health, 2017. 14(1): 1-11.
28. Ramos MA, Droguett LA, Mosleh A, Moura DCM. A human reliability analysis methodology for oil refineries and petrochemical plants operation: Phoenix-PRO qualitative framework. Reliabiltiy Eng Sys Saf. 2020. 193(c): 106672.
29. Zhao Y, Li W, Zhou L, Xiong Y, Jian Y, Cheng M. Research on An Operation Monitoring and Evaluation Technology for Advanced Main Control Room of Nuclear Power Plant. International Conference on Power System Technology (POWERCON), 2018.
30. Yenn TC, Jou YT, Lin CJ, Tsai WS, Hsieh TL. Apply Performance Evaluation Matrix on Investigating Human Error Events in the Main Control Room. 18th International Conference on Nuclear Engineering. 2010.
31. Yang CW, Hsieh TL, Lin SF, Lin CJ, Teng HM, Chiu YF. Operators’ signal-detection performance in video display unit monitoring tasks of the main control room. Saf Sci, 2011. 49(10): 1309-1313.
32. Wang W, Liu X, Qin Y. A modified HEART method with FANP for human error assessment in high-speed railway dispatching tasks. Intl J Ind Ergon, 2018. 67: 242-258.
33. Tajdinan S, Afshari D. Checking of human errors in Ancoiler Device Control Room of Ahvaz Pipe Mill using SHERPA and HET methods in 1390. Iran Occup Health J, 2013. 10(3): 71-78.
34. Sun Y, Zhang Q, Yuan Z, Gao Y, Ding S. Quantitative analysis of human error probability in high-speed railway dispatching tasks. IEEE Access, 2020. 8: 56253-56266.
35. Simonsen E. A comparison of human factors evaluation approaches for nuclear power plant control room assessment and their relation to levels of design decision specificity. Nord Ergon Soc, 2017: 405-114.
36. Sepanloo K, Jafarian R. Analysis of Cognitive Activities of Bushehr Nuclear Power Plant Control Room Operators in Case of Abnormal Conditions. Probabilistic Safety Assessment and Management. 2004; pp 266-271.
37. Pouya AB, Habibi E. The comparative study of evaluating human error assessment and reduction technique and cognitive reliability and error analysis method techniques in the control room of the cement industry. Int J Env Health Eng, 2015. 4(1): 14.
38. Park J, Lee D, Jung W, Kim J. An experimental investigation on relationship between PSFs and operator performances in the digital main control room. Ann Nucl Energy, 2017. 101: 58-68.
39. Nezamodini Z.S, Rezvani Z, Mosavianasl Z. SPAR-H method for human error assessment: A case study in control room of an alcohol plant. Proceedings of the 27th European Safety and Reliability Conference, ESREL 2017; 283-290.
40. Mariana M, T Sahroni.R, Gustiyana T. Fatigue and Human Errors Analysis in Petrochemical and Oil and Gas Plant’s Operation. Proceedings of the International Conference on Industrial Engineering and Operations Management Bandung, Indonesia, March 6-8, 2018.
41. Maddah S, Ghasemi M. Estimating the human error probability using the fuzzy logic approach of CREAM (The case of a control room in a petrochemical industry). Researcher. 2015. 4.
42. Lin CJ, Hsieh TL, Lin SF. Development of staffing evaluation principle for advanced main control room and the effect on situation awareness and mental workload. Nucl Eng Des, 2013. 265: 137-144.
43. Lee SJ, Kim J, Jang SC. Human error mode identification for NPP main control room operations using soft controls. J Nucl Sci Technol, 2011. 48(6): 902-910.
44. Lee JW, Lee YH, Jang TI, Park DH, Kim J. A proposition of human factors approaches to reduce human errors in nuclear power plants. Human Factors and Power Plants and HPRCT 13th Annual Meeting, 2007 IEEE 8th. 2007.16-22.
45. Kodappully M, Srinivasan B, Srinivasan R. Towards predicting human error: Eye gaze analysis for identification of cognitive steps performed by control room operators. J Loss Prev Process Ind, 2016. 42: 35-46.
46. Kim JSJ. Lee Jang SC. HuRECA: human reliability evaluator for computer-based control room actions. Transactions of the Korean Nuclear Society Spring Meeting Jeju, Korea, May 17-18, 2012.
47. Karthick MTP. Robert Kumar CS. HFACS-based FAHP implementation to identify critical factors influencing human error occurrence in nuclear plant control room. Soft Comput, 2020. 24(21): 16577-16591.
48. Karimie SI. Mohammadfam, Mirzaei AM. Human Errors Assessment in the one of the control rooms of a petrochemical industrial company using the extended CREAM method and BN. J Health Saf Work. 2019, 9(2): 105-112.
49. Jou YT, Yenn TC, Lin CJ, Tsai WS, Hsieh TL, The research on extracting the information of human errors in the main control room of nuclear power plants by using Performance Evaluation Matrix. Saf Sci, 2011. 49(2): 236-242.
50. Jang TI, Lee YH, Lim HK. The development of a qualitative analysis method to supplement the analysis of operator's human errors in MCR of NPPS. IFAC Proc Vol, 2007. 40(16): 496-501.
51. Jang I, Kim Y, Park J. Investigating the Effect of Task Complexity on the Occurrence of Human Errors observed in a Nuclear Power Plant Full-Scope Simulator. Reliab Eng Syst Saf, 2021. 214: 107704.
52. Jang I, Kim AR, Al Harbi MAS, Lee SJ, Kang HG, Seong PH. An empirical study on the basic human error probabilities for NPP advanced main control room operation using soft control. Nucl Eng Des, 2013. 257: 79-87.
54. Iqbal MU, Srinivasan R. Simulator based performance metrics to estimate reliability of control room operators. J Loss Prev Process Ind, 2018. 56: 524-530.
55. Hwang SL, Liang SFM, Liu TYY, Yang YJ, Chen PY, Chuang CF. Evaluation of human factors in interface design in main control rooms. Nucl Eng Des, 2009. 239(12): 3069-3075.
56. Horita FE, de Albuquerque JP, Marchezini V. Understanding the decision-making process in disaster risk monitoring and early-warning: A case study within a control room in Brazil. Int J Disaster Risk Reduct, 2018. 28: 22-31.
57. Han SH, Yang H, Im DG. Designing a human–computer interface for a process control room: A case study of a steel manufacturing company. Int J Ind Ergon, 2007. 37(5): 383-393.
58. Grozdanović M, Bijelić B. Ergonomic design of a railway traffic control room: A Serbian experience. Hum Factors Ergon Manuf, 2019. 29(1): 95-105.
59. Grozdanovic M. Interaction between an operator and the control desk at the control room of the railway traffic: A Serbian experience. Hum Factors Ergon Manuf, 2020. 30(3): 221-234.
60. Ghasemi M, Zakerian A, Azhdari M. Control of Human Error and comparison Level risk after correction action With the SHERPA Method in a control Room of petrochemical industry. Iran Occup Health, 2011. 8(3): 2-0.
61. Feng Y, Wang ZQ, Liu JB, Guo YH. Nuclear Power Plants: Innovative Technologies for Instrumentation and Control Systems: International Symposium on Software Reliability, Industrial Safety, Cyber Security and Physical Protection of Nuclear Power Plant Volume 400 of Lecture Notes in Electrical Engineering. Discussion About Issues of Human Error in Digital Control Room of NPP. Springer, 2017. pp 133-141.
62. Feng H, Li Y, Zhang D, Li J. Research on Human Error Analysis in the Simulated Main Control Room of Nuclear Power Plant Based on EEG Brain Network. 2019 IEEE International Conference on Computational Intelligence and Virtual Environments for Measurement Systems and Applications (CIVEMSA), 2019, pp. 1-5.
63. Ding X, Li Z, Dong X, Gao Q, Song F, Wang Q. Effects of information organization and presentation on human performance in simulated main control room procedure tasks. Hum Factors Ergon Manuf, 2015. 25(6): 713-723.
64. Dehghani T, Mahdavi S, Fardosrad N, Rashidi R, Almasian M, Zaroushani V, Kosari M, Movahed M. Evaluating Human Errors using HEART and TRACEr Methods: Case Study at a Petrochemical Plant. Int J Occup Hyg, 2019. 11(4): 247-258.
65. Arsenie P, Hanzu-Pazara R. Human errors and oil pollution from tankers. TransNav, Intl J Marine Nav Saf Sea Transp,2008. 2(4): 409-413.
66. Adl J, Jahangiri M, Saraji J. Analysis of Human Errors Caused by Noise Interference Effect in Isomax Unit of an Oil Refinery.J Petro Res.2005. 15(51): 38-45.
67. Stanton NA, Salmon PM, Rafferty LA, Walker GH, Baber C, Jenkins DP. Human factors methods: a practical guide for engineering and design. 2017: CRC Press.
IssueArticles in Press QRcode
SectionReview Article(s)
Human Error Human Failure Control Room Systematic Review Industry

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Ramezanifar S, Ramezanifar E, Salehi Sahlabadi A. Investigating the Probability of Human Error in Iranian Industrial Control Rooms: A Systematic Review. Int J Occup Hyg. 2022;14(1):xx-xx.