Developing the foundations of a cognition-based human reliability analysis model via mapping task types and performance-influencing factors: Application to radiotherapy

Most human reliability analysis methods have been developed for nuclear power plant applications; this challenges the application of the available techniques to other domains. Indeed, for application to a specific domain, a human reliability analysis method should address the relevant tasks and performance conditions. The aim of this article is to propose a methodology to develop a generic task type–performance-influencing factor structure, specific for application to a domain of interest and directly linked to an underlying cognitive framework of literature. The structure provides the foundation of a human reliability analysis method built on the generic task type concept; it identifies the sector-specific performance-influencing factor effects on the failure probability that the method needs to represent and quantify for each generic task type. The methodology is intended to support a systematic and traceable process to develop the generic task type–performance-influencing factor structure, to ease the review of the process and of its results and, in case, identify and implement changes to the structure. The proposed methodology is applied to the radiotherapy domain allowing the development of sector-specific taxonomies of representative critical tasks, their failure modes, underlying cognitive failure mechanism, and influencing performance-influencing factors. This is part of a broader activity carried out by the Risk and Human Reliability Group at the Paul Scherrer Institute of Switzerland to develop a human reliability analysis method, specific for the radiotherapy domain. The activity is conducted in close cooperation with Paul Scherrer Institute’s Center for Proton Therapy, where a first application of the method is foreseen.

[1]  A. Slonim,et al.  Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care , 2003, Quality & safety in health care.

[2]  David L. Cooke,et al.  Risk analysis in radiation treatment: application of a new taxonomic structure. , 2006, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[3]  L. Verhey,et al.  Immobilizing and Positioning Patients for Radiotherapy. , 1995, Seminars in radiation oncology.

[4]  B. Thomadsen Critique of traditional quality assurance paradigm. , 2008, International journal of radiation oncology, biology, physics.

[5]  David L. Cooke,et al.  Probabilistic Fault Tree Analysis of a Radiation Treatment System , 2007, Risk analysis : an official publication of the Society for Risk Analysis.

[6]  P. F. Frutuoso e Melo,et al.  Human Reliability Modeling of Radiotherapy Procedures by Bayesian Networks and Expert Opinion Elicitation , 2016 .

[7]  T Pawlicki,et al.  Consensus recommendations for incident learning database structures in radiation oncology. , 2012, Medical physics.

[8]  G. Starkschall,et al.  American Association of Physicists in Medicine Radiation Therapy Committee Task Group 53: quality assurance for clinical radiotherapy treatment planning. , 1998, Medical physics.

[9]  Ali Mosleh,et al.  PRA: A PERSPECTIVE ON STRENGTHS, CURRENT LIMITATIONS, AND POSSIBLE IMPROVEMENTS , 2014 .

[10]  Benedick A Fraass,et al.  A method for evaluating quality assurance needs in radiation therapy. , 2008, International journal of radiation oncology, biology, physics.

[11]  Karin Laumann,et al.  Task complexity as a performance shaping factor: A review and recommendations in Standardized Plant Analysis Risk-Human Reliability Analysis (SPAR-H) adaption , 2015 .

[12]  Ali Mosleh,et al.  A data-informed PIF hierarchy for model-based Human Reliability Analysis , 2012, Reliab. Eng. Syst. Saf..

[13]  S Derreumaux,et al.  Lessons from recent accidents in radiation therapy in France. , 2008, Radiation protection dosimetry.

[14]  T. K. Yeung,et al.  Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period. , 2005, Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology.

[15]  Mica R. Endsley,et al.  Toward a Theory of Situation Awareness in Dynamic Systems , 1995, Hum. Factors.

[16]  Jon Espen Skogdalen,et al.  Quantitative risk analysis offshore - Human and organizational factors , 2011, Reliab. Eng. Syst. Saf..

[17]  Liam Chadwick,et al.  Human reliability assessment of a critical nursing task in a radiotherapy treatment process. , 2012, Applied ergonomics.

[18]  Ali Mosleh,et al.  Phoenix - A model-based Human Reliability Analysis methodology: Qualitative Analysis Procedure , 2016, Reliab. Eng. Syst. Saf..

[19]  B Kirwan,et al.  The validation of three human reliability quantification techniques - THERP, HEART and JHEDI: part 1 - technique descriptions and validation issues. , 1996, Applied ergonomics.

[20]  A. D. Swain,et al.  Handbook of human-reliability analysis with emphasis on nuclear power plant applications. Final report , 1983 .

[21]  Sasa Mutic,et al.  The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. , 2016, Medical physics.

[22]  Fang-Fang Yin,et al.  Task Group 142 report: quality assurance of medical accelerators. , 2009, Medical physics.

[23]  Robert R. Hoffman,et al.  Visualization framework of macrocognition functions , 2011, Cognition, Technology & Work.

[24]  J. C. Williams,et al.  Heart—A Proposed Method for Achieving High Reliability in Process Operation by Means of Human Factors Engineering Technology , 2015 .

[25]  Jeremy C. Williams,et al.  Consolidation of the Error Producing Conditions Used in the Human Error Assessment and Reduction Technique (Heart) , 2015 .

[26]  Emilie M. Roth,et al.  The SACADA database for human reliability and human performance , 2014, Reliab. Eng. Syst. Saf..

[27]  Jinkyun Park Scrutinizing inter-relations between performance influencing factors and the performance of human operators pertaining to the emergency tasks of nuclear power plant – An explanatory study , 2011 .

[28]  Barry Kirwan,et al.  CARA: A Human Reliability Assessment Tool for Air Traffic Safety Management - Technical Basis and Preliminary Architecture , 2007, SSS.