Combining task analysis and fault tree analysis for accident and incident analysis: A case study from Bulgaria

Understanding the reasons for incident and accident occurrence is important for an organization's safety. Different methods have been developed to achieve this goal. To better understand the human behaviour in incident occurrence we propose an analysis concept that combines Fault Tree Analysis (FTA) and Task Analysis (TA). The former method identifies the root causes of an accident/incident, while the latter analyses the way people perform the tasks in their work environment and how they interact with machines or colleagues. These methods were complemented with the use of the Human Error Identification in System Tools (HEIST) methodology and the concept of Performance Shaping Factors (PSF) to deepen the insight into the error modes of an operator's behaviour. HEIST shows the external error modes that caused the human error and the factors that prompted the human to err. To show the validity of the approach, a case study at a Bulgarian Hydro power plant was carried out. An incident - the flooding of the plant's basement - was analysed by combining the afore-mentioned methods. The case study shows that Task Analysis in combination with other methods can be applied successfully to human error analysis, revealing details about erroneous actions in a realistic situation. (C) 2008 Elsevier Ltd. All rights reserved.