title: Human Error Analysis in a Permit to Work System: A Case Study in a Chemical Plant.
abstract: BACKGROUND
  A permit to work (PTW) is a formal written system to control certain types of work which are identified as potentially hazardous. However, human error in PTW processes can lead to an accident.
  
  
  METHODS
  This cross-sectional, descriptive study was conducted to estimate the probability of human errors in PTW processes in a chemical plant in Iran. In the first stage, through interviewing the personnel and studying the procedure in the plant, the PTW process was analyzed using the hierarchical task analysis technique. In doing so, PTW was considered as a goal and detailed tasks to achieve the goal were analyzed. In the next step, the standardized plant analysis risk-human (SPAR-H) reliability analysis method was applied for estimation of human error probability.
  
  
  RESULTS
  The mean probability of human error in the PTW system was estimated to be 0.11. The highest probability of human error in the PTW process was related to flammable gas testing (50.7%).
  
  
  CONCLUSIONS
  The SPAR-H method applied in this study could analyze and quantify the potential human errors and extract the required measures for reducing the error probabilities in PTW system. Some suggestions to reduce the likelihood of errors, especially in the field of modifying the performance shaping factors and dependencies among tasks are provided.
authors.affiliation: Research Center for Health Sciences, Department of Occupational Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Mehdi
authors.initials: M
authors.lastname: Jahangiri
authors.affiliation: Student Research Committee, Department of Occupational Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Naser
authors.initials: N
authors.lastname: Hoboubi
authors.affiliation: Student Research Committee, Department of Occupational Health Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Akbar
authors.initials: A
authors.lastname: Rostamabadi
authors.affiliation: Department of Epidemiology, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran.
authors.forename: Sareh
authors.initials: S
authors.lastname: Keshavarzi
authors.affiliation: Department of Health, Safety and Environment (HSE), Zagros Petrochemical Company, Pars Especial Economic Energy Zone (PSEEZ), Asaluyeh, Bushehr, Iran.
authors.forename: Ali Akbar
authors.initials: AA
authors.lastname: Hosseini
keywords: human error; standardized plant analysis risk-human; work permit system