A2212 Systematic human error reduction and prediction approach "SHERPA" in a car pieces montaging company of Iran

Wednesday, March 21, 2012
Ground Floor (Cancun Center)

Fatemeh Amini Fard, HSE, Mapna Co., Tehran, Iran, Islamic Rep.
Introduction
Human error is the key cause of more accident that occurred in industries. For control of errors we should identify: (1) different kinds of human error and (2) why error will occur. This evaluation is implemented in an industrial company in Iran and montage-line, due to complicate, delicacy and sensitive duties, selected for study.

Methods
Analyzing the jobs implemented by HTA technique and for predicting and identifying human errors we used from "SHERPA" method. Finally presented the controller ways for reducing errors. 

Results
The main goal of this study is familiarity with this subject that "how we can implement SHERPA in industries? ". Information's of this study are collected with this following ways: direct observation, interview with relevant division operators, supervisor, experts and analyzing the nature of previous accidents that occurred on that division. Most important causer resources of human error between the 23 operators of montage line were: fatigue, lack of adequate experience, lack of caution due to working at two shifts, Complication of duty, job stress, similarity between work duties, and ignore some hazards due to getting to exist conditions. 

Discussion
This paper is the first case study that was done about human error techniques in montage industries in Iran. So it confront with impediments such as recognition of the kind of error. That finally between 23operators of montage-line we are considered most evident errors, so that study became intelligible. In this montage-line 130 errors were predicted, and more of errors were from "operational error" category and at this category more errors were from "A2" class (implementing in wrong direction). 112 numbers critical errors were predicted and 4 numbers of them were retrieval. Purposed controller and reducer strategies were: using from rotational work system for reducing the exposure, modifying the work instructions, modifying and improving equipment and reducing the work load.