Master of Science / Department of Industrial & Manufacturing Systems Engineering / Malgorzata Rys / Catheter associated urinary tract infections (CAUTIs) are a source of concern in the healthcare industry because they occur more frequently than other healthcare associated infections and the rates of CAUTI have not improved in recent years. The use of urinary catheters is common among patients; between 15 and 25 percent of all hospital patients will use a urinary catheter at some point during their hospitalization (CDC, 2016). The prevalence of urinary catheters in hospitalized patients and high CAUTI occurrence rates led to the application of human factors engineering to develop a tool to help hospitals reduce CAUTI rates. Human reliability analysis techniques are methods used by human factors engineers to quantify the probability of human error in a system. A human error during a catheter insertion has the opportunity to introduce bacteria into the patient’s system and cause a CAUTI; therefore, human reliability analysis techniques can be applied to catheter insertions to determine the likelihood of a human error. A comparison of three human reliability analysis techniques led to the selection of the Cognitive Reliability and Error Analysis Method (CREAM). To predict a patient’s probability of developing a CAUTI, the human error probability found from CREAM is incorporated with several health factors that affect the patient’s risk of developing CAUTI. These health factors include gender, duration, diabetes, and a patient’s use of antibiotics, and were incorporated with the probability of human error using fuzzy logic. Membership functions were developed for each of the health factors and the probability of human error, and the centroid defuzzification method is used to find a crisp value for the probability of a patient developing CAUTI. Hospitals that implement this tool can choose risk levels for CAUTI that places the patient into one of three zones: green, yellow, or red. The placement into the zones depends on the probability of developing a CAUTI. The tool also provides specific best practice interventions for each of the zones.

Grandes avanços têm sido alcançados com as técnicas de análise de segurança dos sistemas essenciais de navegação e performance das aeronaves resultando na diminuição das taxas de acidentes ao longo dos últimos anos. O Relatório de Segurança de 2017 da EASA (European Agency Safety Aviation) apresenta um relevante aumento do número de acidentes não fatais. Este resultado positivo leva ao aumento das evacuações de emergência. O Relatório de Segurança de 2016 da IATA (International Air Transport Association) mostra que em 35% dos acidentes com sobreviventes em Jatos e 55% dos acidentes com sobreviventes em turbo hélice ocorreram com evacuação de emergência. Diante deste cenário, a confiabilidade humana torna-se relevante na interface destes passageiros com o projeto de segurança da cabine durante o procedimento de evacuação de emergência. Para avaliar as características e a contribuição desta interface no sucesso do procedimento de evacuação, é proposta uma metodologia para a análise da interação humana com este sistema estabelecendo um diagrama causal genérico com o objetivo de estudar o mecanismo do erro humano nesta interface. A metodologia proposta utiliza a abordagem das Redes Bayesianas apoiada pela lógica Fuzzy para modelar os Fatores de Desempenho Humano e para verificar, através da diagnose e inferência causal, quais fatores mais influenciam o desempenho humano na execução das tarefas neste ambiente de emergência. Esta pesquisa apresenta uma aplicação da metodologia proposta para analisar as tarefas do ensaio de evacuação de emergência de uma aeronave, focando na quantificação do erro humano na interface com o projeto de segurança da cabine da aeronave. Os resultados da aplicação identificaram o fator situacional: cartão de segurança, marcas na asa e escorregadores, e os fatores individuais: conhecimento e habilidades: interpretação e percepção como aqueles que mais influenciaram no teste do procedimento de evacuação de emergência de uma aeronave. / Great advances have been achieved with the safety assessment techniques of essential aircraft navigation and performance systems due to decreasing of fatal accident rates in recent years. The EASA Annual Safety Report 2017 (European Agency Safety Aviation) presents a relevant increase of non-fatal accidents. This positive results leads to increasing of emergency evacuation. The IATA Safety Report 2016 (International Air Transport Association) presents that 35% of survival accidents with Jet and 55% of survival accidents with Turboprop occurred with emergency evacuation. In view of this scenario, human reliability becomes relevant in the interface of these passengers with the cabin safety design during emergency evacuation procedure. To evaluate this interface features, and the contribution of this interface in the success of evacuation procedure, it is proposed a method for analyzing the human interaction within the system, to establish a generic causal framework aiming at the study of the human error mechanism. The proposed methodology uses the Bayesian Networks approach supported by Fuzzy logic for modelling Human Performance Factors and for verifying, through diagnosis and causal inference, which factors most influence human performance in the execution of tasks in this emergency environment. This research presents an application of this approach to analyze the tasks of the emergency evacuation testing from an aircraft, focusing on the quantification of human error in the interface with aircraft cabin safety design. The results of application has identified the situational factor: safety card, marks on the wing and escape slides, and the individual factors: knowledge and abilities: interpretation and perception as one those most of influenced the emergency evacuation test procedure from an aircraft.

Outcomes from surgery are dependent upon technical performance, as demonstrated by the variability that exists in outcomes achieved by different surgeons following surgery for rectal cancer. It is possible to improve such outcomes by focused training and the adoption of specific surgical techniques, such as the total mesorectal excision (TME) training programme in Stockholm which reduced local recurrence rates of cancer by 50%. It is generally accepted that good surgical technique is the enactment of a series of positive surgical actions, and the avoidance of errors. However, the constituents of good surgical technique for rectal cancer have not yet been studied in sufficient detail to identify the specific associations between individual steps and their consequences. In this study the ergonomic principles of human reliability analysis (HRA) were applied to video recordings of rectal cancer surgery. A system of error definition and identification was developed, utilising a bespoke software solution designed for the project. Calculation of optimal camera angles and position was determined in a virtual operating theatre. Analysis of synchronised footage from multiple camera views was performed, through which over 6,000 errors were identified across 14 procedural tasks. The sequences of events contributing to these errors are reported, and a series of error reduction mechanisms formulated for rectal cancer surgery.

Safeguards and security (S&S) systems for nuclear facilities include material control and accounting (MC&A) and a physical protection system (PPS) to protect nuclear materials from theft, sabotage and other malevolent human acts. The PPS for a facility is evaluated using probabilistic analysis of adversary paths on the basis of detection, delay, and response timelines to determine timely detection. The path analysis methodology focuses on systematic, quantitative evaluation of the physical protection component for potential external threats, and often calculates the probability that the PPS is effective (PE) in defeating an adversary who uses that attack path. By monitoring and tracking critical materials, MC&A activities provide additional protection against inside adversaries, but have been difficult to characterize in ways that are compatible with the existing path analysis methods that are used to systematically evaluate the effectiveness of a site’s protection system. This research describes and demonstrates a new method to incorporate MC&A protection elements explicitly within the existing probabilistic path analysis methodology. MC&A activities, from monitoring to inventory measurements, provide many, often recurring opportunities to determine the status of critical items, including detection of missing materials. Human reliability analysis methods are applied to determine human error probabilities to characterize the detection capabilities of MC&A activities. An object-based state machine paradigm was developed to characterize the path elements and timing of an insider theft scenario as a race against MC&A activities that can move a facility from a normal state to a heightened alert state having additional detection opportunities. This paradigm is coupled with nuclear power plant probabilistic risk assessment techniques to incorporate the evaluation of MC&A activities in the existing path analysis methodology. Event sequence diagrams describe insider paths through the PPS and also incorporate MC&A activities as path elements. This work establishes a probabilistic basis for incorporating MC&A activities explicitly within the existing path analysis methodology to extend it to address insider threats. The analysis results for this new method provide an integrated effectiveness measure for a safeguards and security system that addresses threats from both outside and inside adversaries. / text

Esta tese apresenta uma sistemática para avaliação de confiabilidade humana em mina a céu aberto com vistas à proposição de planos de melhorias para tratativa de falhas humanas. Para tanto, gera-se uma metodologia apoiada na seleção de especialistas para preenchimento da tabela de Análise de Modos e Efeitos de falha (FMEA). A utilização dos especialistas mais consistentes eleva a qualidade e a consistência das avaliações, possibilitando maior coerência das informações, desconsiderando opiniões extremistas e permitindo proposição de melhorias mais assertivas. Além do preenchimento dos índices de Ocorrência, Detecção e Severidade, tradicionalmente existentes na FMEA, propõe-se a utilização do índice de Severidade Humana (SH), que visa quantificar o impacto de cada modo de falha sobre a integridade física dos colaboradores vinculados ao processo em que a falha ocorre. A ocorrência de tais falhas pode gerar acidentes que demandam atendimentos ambulatoriais, afastamentos, fatalidades ou perdas produtivas substanciais. A elaboração dos planos de melhoria dos modos de falha preponderantes é operacionalizada em duas frentes, de acordo com a disponibilidade de tempos até a falha motivados por erros humanos. Mediante número suficiente de tempos até a falha, realiza-se uma modelagem quantitativa com vistas à determinação de intervalos de checagem dos procedimentos associados aos modos de falha preponderantes; além da definição de tal intervalo, gera-se um plano de melhorias para cada modo de falha. No caso de não haver número suficiente de tempos até a falha para modelagem quantitativa, gera-se somente o plano de melhoria para o modo de falha em questão. Os planos de melhorias propostos são focados em comportamentos que tenham relação com aspectos cognitivos (percepção, atenção, memória, raciocínio, juízo, imaginação, pensamento, linguagem, etc.) e sócio-emocionais (autonomia, estabilidade emocional, sociabilidade, capacidade de superar fracassos, curiosidade, perseverança, etc.), os quais impactam na execução dos procedimentos e podem conduzir a falhas. / This thesis presents a system for evaluating human reliability in open pit mine aimed at proposing improvements plans derived from human errors. Therefore, it proposes a methodology that relies on the selection of experts to assess the Failure Mode and Effect Analysis (FMEA). Using the most consistent experts increases the quality and consistency of assessments, enabling more coherence on experts’ opinions, disregarding extremist views and allowing more assertive proposition improvements. In addition to the traditional FMEA indices, i.e. Occurrence rates, Detection and Severity, we propose the Human Severity Index (SH), which aims to quantify the impact of each failure mode upon the physical integrity of employees. The occurrence of such failures can lead to accidents that require outpatient care, absenteeism, fatalities or substantial production losses. The development of improvement plans predominant failure modes is carried out in two fronts, according to the availability of failure times samples motivated by human error. When enough time to failure samples are available, we carry out a quantitative modeling to determine checking intervals for procedures associated with the predominant failure modes; next, an improvement plan for each failure mode is proposed. In case there is no sufficient number of times to failure for quantitative modeling, we generate only the improvement plan for the failure mode in question. The proposed improvement plans are focused on behaviors are related to cognitive (perception, attention, memory, reasoning, judgment, imagination, thought, language, etc.) and socio-emotional (autonomy, emotional stability, sociability, ability to overcome failures , curiosity, perseverance, etc.) aspects.

Master of Science / Department of Industrial & Manufacturing Systems Engineering / Malgorzata J. Rys / According to the Centers for Disease Control and Prevention (2015), urinary tract infections (UTIs) are the most commonly reported healthcare-associated infection (HAI), of which approximately 75% of infections are attributed to the presence of a urinary catheter. Urinary catheters are commonplace within hospitals as approximately 15-25% of patients receive a urinary catheter during their hospitalization, introducing the risk of a catheter associated urinary tract infection (CAUTI) during their stay (CDC, 2015). In recent years there have been efforts to reduce CAUTI in U.S. hospitals; however, despite these efforts, CAUTI rates indicate the need to continue prevention efforts. Researchers have investigated the use of human reliability analysis (HRA) techniques to predict and prevent CAUTI (Griebel, 2016), and this research builds on that topic by applying the Human Error Assessment and Reduction Technique (HEART) to develop a model for a patient’s probability of CAUTI. HEART considers 40 different error-producing conditions (EPCs) present while performing a task, and evaluates the extent to which each EPC affects the probability of an error. This research considers the task of inserting a Foley catheter, where an error in the process could potentially lead to a CAUTI. Significant patient factors that increase a patient’s probability of CAUTI (diabetes, female gender, and catheter days) are also considered, along with obesity which is examined from a process reliability perspective. Under the HEART process, human reliability knowledge and the knowledge of eight expert healthcare professionals are combined to evaluate the probability that a patient will acquire a CAUTI. In addition to predicting the probability of CAUTI, HEART also provides a systematic way to prioritize patient safety improvement efforts by examining the most significant EPCs or process steps. The proposed CAUTI model suggests that 7 of the 26 steps in the catheter insertion process contribute to 95% of the unreliability of the process. Three of the steps are related to cleaning the patient prior to inserting the catheter, two of the steps are directly related to actually inserting the catheter, and two steps are related to maintaining the collection bag below the patient’s bladder. An analysis of the EPCs evaluated also revealed that the most significant factors affecting the process are unfamiliarity, or the possibility of novel events, personal psychological factors, shortage of time, and inexperience. By targeting reliability improvements in these steps and factors, healthcare organizations can have the greatest impact on preventing CAUTI.

Made available in DSpace on 2016-06-02T19:51:51Z (GMT). No. of bitstreams: 1 3820.pdf: 3699560 bytes, checksum: 4015fc6d4e05d4dfaf92839f0980b2a7 (MD5) Previous issue date: 2011-03-03 / The restructuring of production processes throughout the entire petrochemical chain brought impacts on the labor division, resulting in a series of new demands for knowledge and skills, which are added to old ones, in order to maintain the stability and reliability of the production system, under their responsibility. The objective of this thesis is to build a theoretical framework on human reliability and ergonomics as well as the observation and analysis of an oil refinery production system. It aims to identify conflicts and gaps between the strategies and actions developed by the operators as system reliability maintainance agents in their work daily routine, and the organizational managerial approach for human reliability in the company. In order to achieve these goals, the research approach adopted has the characteristics of literature review that encompasses bibliometrics and content analysis, mixing action research methodology and Ergonomic Workplace Analysis in field research. The literature review identified 304 articles about "human reliability in the ISI Web of Knowledge scientific basis, of which only 50 items are classified in the field of ergonomics (16%). The major research stream on human reliability focuses on nominal scenarios, and therefore, in the ergonomics point of view, focuses on the task, i.e., the prescribed work. Another research stream focus on the real work analysis. The Company studied has classical and a mechanistic point of view focuses on the errors identification and construction barriers through procedures, checklists and other prescription alternatives to improve performance in reliability area. It was evident the fundamental role of the worker as an agent of maintenance and construction of system reliability. There are several strategies adopted by operators to mitigate in practice the gap between prescribed and real work. / A reestruturação dos processos produtivos ao longo de toda a cadeia petroquímica trouxe impactos sobre a divisão do trabalho resultando em uma série de novas demandas por conhecimentos e habilidades, que se agregaram as antigas já construídas pelos trabalhadores, para a manutenção da estabilidade e confiabilidade do sistema produtivo sob sua responsabilidade. O objetivo desta dissertação é construir um quadro teórico sobre confiabilidade humana e ergonomia, bem como a observação e análise de um sistema produtivo de uma refinaria de petróleo. Pretende-se identificar os conflitos e lacunas existentes entre as estratégias e ações elaboradas pelos operadores como agentes na manutenção da confiabilidade do sistema em sua rotina de trabalho, e o tipo de opção gerencial de confiabilidade humana implantado pela empresa. Para atingir os objetivos estabelecidos para este trabalho, a abordagem de pesquisa adotada tem características de pesquisa bibliográfica com técnica de bibliometria e análise de conteúdo, mesclando na pesquisa de campo as metodologias de pesquisa-ação e Análise Ergonômica do Trabalho (AET). A revisão de literatura identificou 304 artigos sobre confiabilidade humana na base científica ISI Web of Knowledge, dos quais apenas 50 artigos são classificados na área de ergonomia (16%). Boa parte dessa literatura tem o foco central em cenários nominais, e, portanto, na perspectiva da ergonomia, foca na tarefa, no trabalho prescrito. Menor espaço nas bases científicas é ocupado por trabalhos, cuja preocupação com a confiabilidade humana é centrada no trabalho real. A Empresa estudada apresenta uma visão mecanicista clássica e foca a atuação na área de confiabilidade na identificação dos erros e construção de barreiras através de procedimentos, checklists e outras alternativas de prescrição. Evidenciou-se o papel fundamental do trabalhador como um agente de manutenção e de construção de elementos de confiabilidade do sistema. São muitas as estratégias adotadas pelos operadores para mitigar na prática as lacunas entre o trabalho prescrito e o real.

Esta tese apresenta uma sistemática para avaliação de confiabilidade humana em mina a céu aberto com vistas à proposição de planos de melhorias para tratativa de falhas humanas. Para tanto, gera-se uma metodologia apoiada na seleção de especialistas para preenchimento da tabela de Análise de Modos e Efeitos de falha (FMEA). A utilização dos especialistas mais consistentes eleva a qualidade e a consistência das avaliações, possibilitando maior coerência das informações, desconsiderando opiniões extremistas e permitindo proposição de melhorias mais assertivas. Além do preenchimento dos índices de Ocorrência, Detecção e Severidade, tradicionalmente existentes na FMEA, propõe-se a utilização do índice de Severidade Humana (SH), que visa quantificar o impacto de cada modo de falha sobre a integridade física dos colaboradores vinculados ao processo em que a falha ocorre. A ocorrência de tais falhas pode gerar acidentes que demandam atendimentos ambulatoriais, afastamentos, fatalidades ou perdas produtivas substanciais. A elaboração dos planos de melhoria dos modos de falha preponderantes é operacionalizada em duas frentes, de acordo com a disponibilidade de tempos até a falha motivados por erros humanos. Mediante número suficiente de tempos até a falha, realiza-se uma modelagem quantitativa com vistas à determinação de intervalos de checagem dos procedimentos associados aos modos de falha preponderantes; além da definição de tal intervalo, gera-se um plano de melhorias para cada modo de falha. No caso de não haver número suficiente de tempos até a falha para modelagem quantitativa, gera-se somente o plano de melhoria para o modo de falha em questão. Os planos de melhorias propostos são focados em comportamentos que tenham relação com aspectos cognitivos (percepção, atenção, memória, raciocínio, juízo, imaginação, pensamento, linguagem, etc.) e sócio-emocionais (autonomia, estabilidade emocional, sociabilidade, capacidade de superar fracassos, curiosidade, perseverança, etc.), os quais impactam na execução dos procedimentos e podem conduzir a falhas. / This thesis presents a system for evaluating human reliability in open pit mine aimed at proposing improvements plans derived from human errors. Therefore, it proposes a methodology that relies on the selection of experts to assess the Failure Mode and Effect Analysis (FMEA). Using the most consistent experts increases the quality and consistency of assessments, enabling more coherence on experts’ opinions, disregarding extremist views and allowing more assertive proposition improvements. In addition to the traditional FMEA indices, i.e. Occurrence rates, Detection and Severity, we propose the Human Severity Index (SH), which aims to quantify the impact of each failure mode upon the physical integrity of employees. The occurrence of such failures can lead to accidents that require outpatient care, absenteeism, fatalities or substantial production losses. The development of improvement plans predominant failure modes is carried out in two fronts, according to the availability of failure times samples motivated by human error. When enough time to failure samples are available, we carry out a quantitative modeling to determine checking intervals for procedures associated with the predominant failure modes; next, an improvement plan for each failure mode is proposed. In case there is no sufficient number of times to failure for quantitative modeling, we generate only the improvement plan for the failure mode in question. The proposed improvement plans are focused on behaviors are related to cognitive (perception, attention, memory, reasoning, judgment, imagination, thought, language, etc.) and socio-emotional (autonomy, emotional stability, sociability, ability to overcome failures , curiosity, perseverance, etc.) aspects.

Esta tese apresenta uma sistemática para avaliação de confiabilidade humana em mina a céu aberto com vistas à proposição de planos de melhorias para tratativa de falhas humanas. Para tanto, gera-se uma metodologia apoiada na seleção de especialistas para preenchimento da tabela de Análise de Modos e Efeitos de falha (FMEA). A utilização dos especialistas mais consistentes eleva a qualidade e a consistência das avaliações, possibilitando maior coerência das informações, desconsiderando opiniões extremistas e permitindo proposição de melhorias mais assertivas. Além do preenchimento dos índices de Ocorrência, Detecção e Severidade, tradicionalmente existentes na FMEA, propõe-se a utilização do índice de Severidade Humana (SH), que visa quantificar o impacto de cada modo de falha sobre a integridade física dos colaboradores vinculados ao processo em que a falha ocorre. A ocorrência de tais falhas pode gerar acidentes que demandam atendimentos ambulatoriais, afastamentos, fatalidades ou perdas produtivas substanciais. A elaboração dos planos de melhoria dos modos de falha preponderantes é operacionalizada em duas frentes, de acordo com a disponibilidade de tempos até a falha motivados por erros humanos. Mediante número suficiente de tempos até a falha, realiza-se uma modelagem quantitativa com vistas à determinação de intervalos de checagem dos procedimentos associados aos modos de falha preponderantes; além da definição de tal intervalo, gera-se um plano de melhorias para cada modo de falha. No caso de não haver número suficiente de tempos até a falha para modelagem quantitativa, gera-se somente o plano de melhoria para o modo de falha em questão. Os planos de melhorias propostos são focados em comportamentos que tenham relação com aspectos cognitivos (percepção, atenção, memória, raciocínio, juízo, imaginação, pensamento, linguagem, etc.) e sócio-emocionais (autonomia, estabilidade emocional, sociabilidade, capacidade de superar fracassos, curiosidade, perseverança, etc.), os quais impactam na execução dos procedimentos e podem conduzir a falhas. / This thesis presents a system for evaluating human reliability in open pit mine aimed at proposing improvements plans derived from human errors. Therefore, it proposes a methodology that relies on the selection of experts to assess the Failure Mode and Effect Analysis (FMEA). Using the most consistent experts increases the quality and consistency of assessments, enabling more coherence on experts’ opinions, disregarding extremist views and allowing more assertive proposition improvements. In addition to the traditional FMEA indices, i.e. Occurrence rates, Detection and Severity, we propose the Human Severity Index (SH), which aims to quantify the impact of each failure mode upon the physical integrity of employees. The occurrence of such failures can lead to accidents that require outpatient care, absenteeism, fatalities or substantial production losses. The development of improvement plans predominant failure modes is carried out in two fronts, according to the availability of failure times samples motivated by human error. When enough time to failure samples are available, we carry out a quantitative modeling to determine checking intervals for procedures associated with the predominant failure modes; next, an improvement plan for each failure mode is proposed. In case there is no sufficient number of times to failure for quantitative modeling, we generate only the improvement plan for the failure mode in question. The proposed improvement plans are focused on behaviors are related to cognitive (perception, attention, memory, reasoning, judgment, imagination, thought, language, etc.) and socio-emotional (autonomy, emotional stability, sociability, ability to overcome failures , curiosity, perseverance, etc.) aspects.

Submitted by Pedro Barros (pedro.silvabarros@ufpe.br) on 2018-06-20T22:54:11Z No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) TESE Marilia Abílio Ramos.pdf: 6997571 bytes, checksum: 1514e881a0919bde7d2b45038eed3a91 (MD5) / Made available in DSpace on 2018-06-20T22:54:11Z (GMT). No. of bitstreams: 2 license_rdf: 811 bytes, checksum: e39d27027a6cc9cb039ad269a5db8e34 (MD5) TESE Marilia Abílio Ramos.pdf: 6997571 bytes, checksum: 1514e881a0919bde7d2b45038eed3a91 (MD5) Previous issue date: 2017-04-07 / ANP (Agência Nacional do Petróleo) / Petrobras / The oil industry has grown in recent decades in terms of quantity of facilities and process complexity. However, human and material losses still occur due to major accidents at the facility. The analysis of these accidents reveals that many involve human failures that, if prevented, could avoid such accidents. These failures, in turn, can be identified, modeled and quantified through Human Reliability Analysis (HRA), which forms a basis for prioritization and development of safeguards for preventing or reducing the frequency of accidents. The most advanced and reliable HRA methods have been developed and applied in nuclear power plant operations, while the petroleum industry has usually applied Quantitative Risk Analysis (QRA) focusing on process safety in terms of technical aspects of the operation and equipment. This thesis demonstrates that the use of HRA in oil refining and petrochemical operations allows the identification and analysis of factors that can influence the behavior of operators as well as the potential human errors that can contribute to the occurrence of an accident. Existing HRA methodologies, however, were mainly developed for the nuclear industry. Thus, they may not reflect the specificities of refining and petrochemical plants regarding the interaction of the operators with the plant, the failure modes of the operators and the factors that influence their actions. Thus, this thesis presents an HRA methodology developed specifically for use in this industry, HERO - Human Error in Refinery Operations HRA Methodology. The Phoenix HRA methodology was used as a basis, which has three layers i) a crew response tree (CRT), which models the interaction between the crew and the plant; ii) a human response model, modeled through fault trees, that identifies the possible crew failures modes (CFMs); and (iii) "contextual factors" known as performance influencing factors (PIFs), modeled through Bayesian networks. In addition to building on such a structure, HERO's development relied on interviews with HRA specialists, visitations to a refinery and its control room, and analysis of past oil refineries accidents - four accidents were analyzed in detail. The methodology developed maintains the three-layer structure and has a guideline flowchart for the construction of the CRT, in order to model the team-plant interactions in oil refining and petrochemical operations; it also features CFMs and PIFs developed specifically for this industry, with definitions that make them easily relatable by an analyst. Finally, the methodology was applied to three potential accidental scenarios of refinery operations. In one of these scenarios, it was combined with a QRA to illustrate how an HRA can be applied to a traditional QRA and to demonstrate the influence of PIFs and of human error probability on the final risk. The use of this methodology for HRA of refineries and petrochemical plants operations can enhance this industry safety and allow for solid riskbased decisions. / A indústria de petróleo teve grande crescimento nas últimas décadas em termos de quantidade de instalações e complexidade de processo. No entanto, perdas humanas e materiais ainda ocorrem devido a acidentes graves nas instalações. A análise desses acidentes revela que muitos envolvem falhas humanas que poderiam ser prevenidas de forma a evitar tais acidentes. Estas falhas, por sua vez, podem ser identificadas, modeladas e quantificadas através da Análise de Confiabilidade Humana (ACH), que forma uma base para priorização e desenvolvimento de salvaguardas na prevenção ou redução da frequência de acidentes. Os métodos de ACH mais avançados e confiáveis têm sido desenvolvidos e aplicados nas operações de controle de plantas nucleares; já a indústria de petróleo tem usualmente aplicado a Análise Quantitativa de Risco (AQR) com foco na segurança de processo em termos técnicos da operação e equipamentos. Esta tese demonstra que o uso da ACH em operações de refino e petroquímica possibilita a identificação e análise dos fatores que podem influenciar o comportamento do operador bem como as potenciais falhas humanas que podem contribuir para a ocorrência de um acidente. As metodologias de ACH existentes, no entanto, foram desenvolvidas para a indústria nuclear. Desta forma, elas não refletem as especificidades de refino e petroquímica no que se refere à interação dos operadores com a planta, aos modos de falha dos operadores e aos fatores que influenciam suas ações. Assim, esta tese apresenta uma metodologia de ACH desenvolvida especificamente para uso nessa indústria, a HERO - Human Error in Refinery Operations HRA Methodology. Como base, utilizou-se a Metodologia Phoenix, que possui três camadas i) uma árvore de resposta da equipe (crew response tree - CRT), que modela a interação da equipe com a planta; ii) um modelo de resposta humana, modelado através de árvores de falhas, que identifica os possíveis modos de falhas da equipe (crew failures modes - CFMs); e iii) os “fatores contextuais” conhecidos como fatores de desempenho ou performance influencing factors (PIFs), modelados através de redes Bayesianas. Além de basear-se em tal estrutura, o desenvolvimento da HERO apoiou-se em entrevistas com especialistas em ACH, visitas a uma refinaria e sua sala de controle e na análise de estudos de acidentes passados em refinarias – foram analisados em detalhe quatro acidentes. A metodologia desenvolvida mantém a estrutura de três camadas e possui um fluxograma-guia para construção da CRT, de forma a modelar as interações equipe-planta na operação de refino e petroquímicas; ela também apresenta CFMs e PIFs desenvolvidos especificamente para esta indústria, com definições que os tornam facilmente identificáveis por um analista. Por fim, a metodologia foi aplicada a três cenários acidentais de operações de refinaria. Em um destes cenários, ela foi conjugada a uma AQR de forma a ilustrar como uma ACH pode ser aplicada a uma tradicional AQR e para demonstrar a influência dos PIFs e da Probabilidade de Erro Humano no risco final. Espera-se que o uso da metodologia proposta nesta tese poderá aumentar a segurança em refinarias e petroquímicas e permitir sólidas decisões baseadas no risco.