یک چارچوب بهبود فرایند مبتنی بر ارزیابی قابلیت اطمینان انسان: یک مطالعه موردی در صنعت پالایش نفت

مشهدی, فرشته; وسیلی, محمدرضا; کاظمی, سیدمحمد; جهانگیری, مهدی; کرباسیان, مهدی

doi:10.22034/sep.2026.2096894.1538

یک چارچوب بهبود فرایند مبتنی بر ارزیابی قابلیت اطمینان انسان: یک مطالعه موردی در صنعت پالایش نفت

مقالات آماده انتشار

نوع مقاله : پژوهشی

نویسندگان

فرشته مشهدی ¹

محمدرضا وسیلی ²

سیدمحمد کاظمی ³

مهدی جهانگیری ⁴

مهدی کرباسیان ⁵

¹ گروه مهندسی صنایع، واحد نجف‌آباد، دانشگاه آزاد اسلامی، نجف‌آباد، ایران

² گروه مهندسی صنایع، واحد لنجان، دانشگاه آزاد اسلامی، اصفهان، ایران

³ گروه مهندسی صنایع، واحد اصفهان (خوراسگان)، دانشگاه آزاد اسلامی، دانشگاه آزاد اسلامی، اصفهان، ایران

⁴ گروه مهندسی بهداشت حرفه‌ای و ایمنی، دانشکده بهداشت، دانشگاه علوم پزشکی شیراز، شیراز، ایران

⁵ گروه مهندسی صنایع، مجتمع دانشگاهی مدیریت و مهندسی صنایع، دانشگاه صنعتی مالک اشتر، تهران، ایران

10.22034/sep.2026.2096894.1538

چکیده

در صنایع فرایندی، عملکرد ایمن و پایدار سیستم‌ها تا حد زیادی به قابلیت اطمینان انسان در انجام وظایف حساس، به‌ویژه در شرایط اضطراری، وابسته است. مانورهای واکنش در شرایط اضطراری به‌عنوان یکی از مهم‌ترین رویکردهای افزایش آمادگی سازمانی در مقابله با حوادث تعریف و اجرا می‌شوند؛ ازاین‌رو، بهبود فرایند اجرای آن‌ها اهمیت دارد. باوجود توسعه روش‌های مختلف ارزیابی قابلیت اطمینان انسان، بسیاری از مطالعات بر برآورد احتمال خطای انسانی تمرکز داشته و کمتر به شناسایی عوامل مؤثر بر عملکرد انسان و تبدیل نتایج ارزیابی به اقدامات بهبود فرایند پرداخته‌اند. در این تحقیق، یک چارچوب بهبود فرایند مبتنی بر ارزیابی قابلیت اطمینان انسان با عنوان DMAIC-HRA پیشنهاد شد. این چارچوب برای مانور اضطراری نشت گازهای سمی و خطرناک در یک پالایشگاه نفت تا مرحله پیشنهاد اقدام‌های اصلاحی اجرا شد. به‌منظور ارزیابی قابلیت اطمینان انسان، یک روش تلفیقی با عنوان SLIM-SHERPA پیشنهاد شد. نتایج نشان داد قابلیت اطمینان انسان در فرایند مورد مطالعه 09/87 درصد است. مچنین، از میان هفده فعالیت بررسی‌شده، بیشترین احتمال خطا مربوط به فعالیت «اعلام به مرکز» با مقدار 1148/0 و کمترین احتمال خطا مربوط به فعالیت «مصاحبه» با مقدار 0048/0 بود. بر اساس نتایج ارزیابی، اقدامات اصلاحی برای بهبود فرایند پیشنهاد شد. چارچوب پیشنهادی می‌تواند به‌عنوان رویکردی نظام‌مند برای شناسایی نقاط ضعف انسانی، کاهش احتمال خطا و ارتقای مدیریت ایمنی در صنایع فرایندی مورد استفاده قرار گیرد. اگرچه نتایج مطالعه موردی ممکن است مستقیماً قابل‌تعمیم به سایر سازمان‌ها نباشد، چارچوب ارائه‌شده قابلیت استفاده در ارزیابی و بهبود سایر فرایندهای سازمانی را دارد.

تازه های تحقیق

پیشنهاد چارچوب بهبود فرآیند مبتنی بر ارزیابی قابلیت اطمینان انسانی
پیشنهاد روشی برای ارزیابی قابلیت اطمینان انسانی از طریق یکپارچه‌سازی تکنیک‌های SLIM و SHERPA
شناسایی و تعیین وزن‌های نسبی عوامل شکل‌دهنده عملکرد
شناسایی خطاهای بالقوه انسانی در سناریوی پاسخ اضطراری ناشی از نشت گاز در پالایشگاه نفت

کلیدواژه‌ها

ارزیابی قابلیت اطمینان انسان

عوامل شکل‌دهنده عملکرد

خطای انسانی

مانور اضطراری نشت گازهای سمی و خطرناک

پالایشگاه نفت

موضوعات

مهندسی صنایع

عنوان مقاله English

A Process Improvement Framework Based on Human Reliability Assessment: A Case Study in the Oil Refining Industry

نویسندگان English

Fereshteh Mashhadi ¹

Mohammadreza Vasili ²

Seyed Mohammad Kazemi ³

Mehdi Jahangir ⁴

Mahdi Karbasian ⁵

¹ Department of Industrial Engineering, Na.C., Islamic Azad University, Najafabad, Iran

² Department of Industrial Engineering, Lenj.C., Islamic Azad University, Isfahan, Iran

³ Department of Industrial Engineering, Is.C., Islamic Azad University, Isfahan, Iran

⁴ Department of Occupational Health and Safety Engineering, School of Health, Shiraz University of Medical Sciences, Shiraz, Iran

⁵ Department of Industrial Engineering, Malek-e-Ashtar University of Technology, Tehran, Iran

چکیده English

The safe and reliable operation of process industries largely depends on human reliability in performing safety-critical tasks, particularly under emergency conditions. Emergency response scenarios are among the most important approaches for enhancing organizational preparedness against industrial accidents; therefore, improving their execution process is of significant importance. Despite the development of various Human Reliability Assessment methods, previous studies have mainly focused on estimating human error probabilities, with limited attention to identifying key performance influencing factors and translating assessment results into practical improvement actions. This study proposes a process improvement framework based on Human Reliability Assessment, named DMAIC-HRA. The proposed framework was applied to a toxic and hazardous gas leak emergency response scenario in an oil refinery up to the stage of developing improvement actions. An integrated SLIM–SHERPA approach was developed to assess human reliability by combining human error identification with reliability estimation. The results indicated that the overall human reliability of the investigated process was 87.09%. Among the seventeen analyzed activities, the highest human error probability was related to the “Notification to the Control Center” activity (0.1148), while the lowest was associated with the “Interview” activity (0.0048). Based on the assessment findings, corrective actions were proposed to improve the emergency response process. The proposed framework provides a systematic approach for identifying human performance weaknesses, reducing the likelihood of human error, and enhancing safety management in high-risk process industries. Although the case study results may not be directly generalizable to other organizations, the proposed framework can be adapted for assessing and improving various organizational processes.

کلیدواژه‌ها English

Human Reliability Assessment

Performance Shaping Factors

Human Error

Toxic and Dangerous Gas Leak Maneuver

Oil Refinery

Copyright © Fereshteh Mashhadi, Mohammadreza Vasili, Seyed Mohammad Kazemi, Mehdi Jahangiri, Mahdi Karbasian

License

This article is released under the Creative Commons Attribution (CC BY 4.0) license. Anyone is free to copy, share, translate, and adapt this article for any purpose, whether commercial or non-commercial, as long as proper citation is given to the authors and original publication.

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