Ruckart Perri Zeitz, Burgess Paula A
Agency for Toxic Substances and Disease Registry, Division of Health Studies, 1600 Clifton Road NE, MS E-31, Atlanta, GA 30333, USA.
J Hazard Mater. 2007 Apr 11;142(3):747-53. doi: 10.1016/j.jhazmat.2006.06.117. Epub 2006 Jul 3.
Human error has played a role in several large-scale hazardous materials events. To assess how human error and time of occurrence may have contributed to acute chemical releases, data from the Hazardous Substances Emergency Events Surveillance (HSEES) system for 1996-2003 were analyzed. Analyses were restricted to events in mining or manufacturing where human error was a contributing factor. The temporal distribution of releases was also evaluated to determine if the night shift impacted releases due to human error. Human error-related events in mining and manufacturing resulted in almost four times as many events with victims and almost three times as many events with evacuations compared with events in these industries where human error was not a contributing factor (10.3% versus 2.7% and 11.8% versus 4.5%, respectively). Time of occurrence of events attributable to human error in mining and manufacturing showed a widespread distribution for number of events, events with victims and evacuations, and hospitalizations and deaths, without apparent increased occurrence during the night shift. Utilizing human factor engineering in both front-end ergonomic design and retrospective incident investigation provides one potential systematic approach that may help minimize human error in workplace-related acute chemical releases and their resulting injuries.
人为失误在几起大规模危险物质事件中都起到了作用。为了评估人为失误和事件发生时间可能如何导致急性化学品泄漏，对1996年至2003年有害物质应急事件监测（HSEES）系统的数据进行了分析。分析仅限于采矿或制造业中人为失误是一个促成因素的事件。还评估了泄漏的时间分布，以确定夜班是否因人为失误而影响泄漏。与这些行业中人为失误不是促成因素的事件相比，采矿和制造业中与人为失误相关的事件导致的有受害者的事件数量几乎多出四倍，疏散事件数量几乎多出两倍（分别为10.3%对2.7%和11.8%对4.5%）。采矿和制造业中可归因于人为失误的事件发生时间在事件数量、有受害者和疏散的事件、住院和死亡方面呈现广泛分布，夜班期间没有明显增加。在前端人体工程学设计和回顾性事件调查中运用人因工程学提供了一种潜在的系统方法，可能有助于将与工作场所相关的急性化学品泄漏及其造成的伤害中的人为失误降至最低。
