A study on human error in a blowout accident in well operation

This paper analyzes human errors, which caused Blow Out accident in China in 2003 by incorporating organizational conditions. Empirical studies show that organizational factors play an important role in creating contexts for human errors. The analyzing procedure outlined in the paper is a combination of three techniques, m-SHELL, FTA and 4E-4M, used for performing HRA in the context of PSA. It includes a process of quantifying the criticality of the organizational influence factors. Finally, with these criticality indexes, the most vulnerable parts in the well drilling system are indicated, and possible and practicable countermeasures are suggested.