Journal of Loss Prevention in the Process Industries 30 (2014) 113e123

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Journal of Loss Prevention in the Process Industries

journal homepage: www.elsevier.com/locate/jlp

A framework for human error risk analysis of coal mine emergency

evacuation in China
Lijing Wang a, *, Yanlong Wang a, 1, Qiyan Cao a, 1, Xiaodong Li a, 1, Jinquan Li b, Xinwen Wu c
a
School of Aeronautic Science and Engineering, Beihang University, 37th Xuanyuan Road, Haidian District, Beijing, 100191, China
b
Huaibei Coal Mining Group Co., Ltd., Huaibei, Anhui, 236000, China
c
Tongjialiang Mine of Datong Coal Mine Group Co., Ltd., Datong, Shanxi, 037025, China

a r t i c l e i n f o a b s t r a c t

Article history: Evacuation from underground coal mine in emergency as soon as possible makes the difference between
Received 12 December 2013 life and death. Human factors have an important impact on a successful evacuation, but literature review
Received in revised form shows that there is a lack of consideration of human error risk during coal mine emergency evacuation in
24 March 2014
China. To address the above problems, in this paper, we established a framework for human error risk
Accepted 4 May 2014
analysis of coal mine emergency evacuation, consisting of scenario and task analysis, risk assessment and
risk reduction. A general evacuation procedure which is applicable for different causes is detailed
through the scenario and task analysis. A new method based on expert judgment, named OGI-Model, is
Keywords:
Coal mine emergency evacuation
proposed to evaluate the reliability of human safety barrier. In this new approach, human safety barrier is
Human factors divided into three sub-barriers, i.e., organization safety sub-barrier (OSSB), group safety sub-barrier
Human error (GSSB), and individual safety sub-barrier (ISSB). Each sub-barrier consists of a series of concrete mea-
Risk analysis sures against specific evacuation actions. An example is provided in this paper to demonstrate the use of
Safety barriers this framework and its effectiveness.
© 2014 Elsevier Ltd. All rights reserved.

1. Introduction
1.1. Motivation and necessity
According to accident statistics and rescue experience, the
instantaneous death at the first scene of a coal mine accident, such
as explosion and collapse, accounts for less than 10% of the total
death. Mostly due to oxygen depletion caused by explosion, high
concentrations of toxic gases, escape routes are blocked and unable
to withdraw to a safe refuge area or evacuate from coal mine timely
(Wu, Gao, & Li, 2011). Therefore, it is essential to research emer-
gency evacuation of coal mine.
Successful evacuation depends on the available material
resource, appropriate personnel actions and their combination
(National Research Council, 2013). In the aspect of material re-
sources, according to China State Administration of Work Safety
* Corresponding author. Tel.: þ86 01082338976.
E-mail addresses: wanglijing505@126.com, wanglijing505@163.com (L. Wang),
wyllaf@sina.com (Y. Wang).
1
Tel.: þ86 01082338976.
and State Administration of Coal Mine Safety, by the end of June
2013, the Six Major Systems, including the emergency refuge sys-
tem, should have been established in all of China's underground
coal mines for the improvement of security and reduction of death
in mine accident (He & Song, 2012). However, vast majority of the
existing literature focuses on system infrastructure, specification
and standard (Jiping, 2011; Wu et al., 2011; Yang & Wu, 2012),
which shows a lack of discussion on the risk caused by human error
during coal mine emergency evacuation. With a review of the
previous major accident investigation reports, descriptions or
evaluations on human behavior error during emergency were not
found, except for a simple summary on human errors which were
considered to be the cause of the incident.
Mine emergency evacuation is a typical emergency response
process. Much of emergency response process relies upon human
activities, such as detection of alarming, decision-making, activities
to control the hazard, evacuation, etc. Woodcook, in his work on
human factors analysis in high risk environment, pointed out that
emergency response is the last defense barrier to prevent loss of
life, injury or damage to the environment (Woodcock & Zachary,
2013). Therefore, the research on human errors in coal mine
emergency evacuation is of high importance.

http://dx.doi.org/10.1016/j.jlp.2014.05.007
0950-4230/© 2014 Elsevier Ltd. All rights reserved.
114 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123

1.2. Research achievements
1.2.1. Establishment of a framework
In this paper, we established a framework for human errors risk
analysis of China's coal mine emergency evacuation. The framework
provides the user with a convenient human reliability analysis (HRA)
tools to assess and reduce coal mine emergency evacuation risk
caused by human errors. Thereby, the survival rate in an accident will
increase. The framework consists of three parts, i.e., scenario and task
analysis, risk assessment and risk reduction. First, combined with the
actual situation of China's coal productions, a general procedure
which is applicable to evacuations caused by different reasons was
detailed based on hierarchical task analysis (HTA). Second, appro-
priate performance shape factors were selected according to the
scenario to be evacuated, and the probability of failure was quanti-
tatively calculated by the Success Likelihood Index Methodology
(SLIM) and the severity was evaluated through a consequence table
for each evacuation action. These results were then combined in a risk
matrix to identify hazardous evacuation steps. Finally, risk graph and
bowetie diagram were chosen to analyze the requirement for safety
barriers, the available safety barriers and their reliability. The frame-
work is presented in detail in Fig. 1.
1.2.2. A new method to estimate the reliability of human safety
barrier
In Accident Risk Assessment Methodology for Industries (ARA-
MIS), the human safety barrier is named as the safety barrier based
on human actions and their level of confidence (LC) are derived
from accident investigation and incident reports (Andersen et al.,
2004). The LC based on historical data can represent the effec-
tiveness of human safety barriers to a certain extent, but it cannot
reflect the actual performance of the newly improved measures (De
Dianous & Fievez, 2006). Therefore, in this paper, human safety
barrier was divided into three sub-barriers, i.e., individual, group
and organizational, and each sub-barrier contains a number of
specific measures intended to relevant actions. Then through
expert subjective judgment methods the effectiveness and the
relative importance (weight) of these measures were determined,
thereby the LC of human safety barrier can be obtained with a
mathematical method. Compared to ARAMIS methodology, the
new method gets a more reasonable LC to better reflect the actual
reliability of human safety barrier. In addition, the method also
gives specific recommendations for emergency evacuation on hu-
man and organizational safety measures.
The structure of this paper is organized as follows. The first
section describes the motivation and results of this study. The
second section reviews the research status on emergency evacua-
tion in different industries and gives a brief introduction to the
methods selected to develop the framework in this paper. The third
section describes the new method to calculate the LC of human
safety barrier. The fourth section details the implementation pro-
cedure of this framework and takes gas explosion as an example to
demonstrate the use of the framework and its applicability. The
fifth part gives the conclusion.

2. Review and selection of risk analysis methods

Scenario and Task Analysis
Scenario description and Many industries around the world have carried out research on
analysis human factors in emergency evacuation (Deacon, Amyotte, Khan, &
MacKinnon, 2013; Gamberini, Cottone, Spagnolli, Varotto, &
Determine Emergency Mantovani, 2003; Kennedy, 1993; Lee, Kim, Park, & Park, 2003;
Evacuation Procedures Ronchi, Colonna, & Berloco, 2013; Vanem & Rolf, 2006). This sec-
tion provides a review of the research status of risk assessment on
emergency evacuation and the related methods. Then appropriate
methods were chosen to establish the framework illustrated in Fig.1.

Risk Consequence
2.1. Scenario and task analysis
Quantification Analysis

Acceptance Scenario and task analysis is the first step in the risk evaluation.
Criteria Here we need to determine the scope and context for operators to
perform their tasks and how the tasks should be performed (Li,
Jointly Assessment
Chen, Zhang, & Dai, 2011). Hierarchical task analysis (HTA) is a
Quantified Risk Assessment widely used task analysis method which helps to identify the main
goal and break it up into concrete steps and provide a well-
No Is the risk structured overview of the work processes even in realistically
Required LC
Analysis tolerable sized examples. It is an easy method of gathering and organizing
information about human activities and human interaction, and
Yes
enables the analyst to find safety-critical tasks (Marhavilas,
Safety Barriers Koulouriotis, & Gemeni, 2011). The resultant HTA gives greater
LC Evaluation detail about the main goals and can be evaluated in terms of risk.
Therefore, HTA method was chosen to obtain a preliminary coal
mine emergency evacuation procedures, and after the panel re-
Barriers
Effectiveness view, a final procedure composed of three phases, i.e., awareness,
Evaluation escape and emergency refuge, was determined eventually. The
three phases can be further divided into 12 independent actions. It
is a general procedure which is applicable to withdrawals caused by
No Is the LC Yes different initiations.
Enough
2.2. Risk assessment techniques
Risk Reduction
Risk assessment is by assessing the level of risk to identify high-
Fig. 1. Framework for human error risk analysis of coal mine emergency evacuation. risk operations, and then take further targeted measures. Risk is a
 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123
Table 1
Several representative risk assessment methods (International Electrotechnical
Commission, 2009; Marhavilas et al., 2011).
Several risk assessment methodologies
C Delphi method C Risk matrix C The proportional
risk assessment
technique (PRAT)
C Hazard and Operational C Risk index C The Predictive,
Analysis HAZOP Epistemic Approach
(PEA)Method
C Business impact analysis C The Clinical Risk C FN curve
and Error Analysis
Method (CREAM)
function of the probability of failure on demand and its conse-
quences (Deacon et al., 2013). Hence risk assessment includes two
aspects, which are to determine the probability of occurrence of a
risk as well as the severity of its consequence. Table 1 lists some of
the common risk assessment approaches. Among them, risk matrix
is evaluated as SA in IEC/ISO31010, that is to say, it is very suitable
for risk assessment (International Electrotechnical Commission,
2009). As an easy and graphic method, risk matrix is also a well-
accepted industry practice. Moreover, it can divide risk into
different levels quickly, while providing a quantitative analysis. For
these reasons, risk matrix is used in this paper for risk assessment
to identify the high risk steps and point out the direction to take
corrective measures.
Quantification of the probabilities of human error risk is
generally conducted with human reliability analysis (HRA) method,
which has now developed into three generations. Fig. 2 shows
some of the typical methods of the three generations. Success
likelihood index methodology (SLIM) was first developed by
Embrey (1983) for the US Nuclear Regulatory Commission. The
basic rationale underlying SLIM is that the likelihood of an error
occurring in a particular situation depends on the combined effects
of a relatively small set of performance shaping factors (PSFs). It is
assumed that an expert judge is able to assess the relative impor-
tance (weight) of each PSF with regard to its effect on reliability and
can make a numerical rating of how good or bad the PSFs are in the
task being evaluated. SLIM is an expert judgment methodology
with a more rigorous theoretical foundation (Kirwan, 1998), mainly
used for multi-attribute analysis of human reliability, especially
suitable for situations that human error data are very poor. Kirwan
(1994) noted that if the HEPs are calibrated with other, ‘known’
HEPs, they are likely to fall within the right ‘ballpark’. Due to a lack
of historical data on coal mine emergency evacuation, SLIM was
chosen in this article.
Risk Quantification Methodologies
The First Generation The Second Generation
SLIM
AIPA
HCR
THERP
HEART
OAT
ASEP
APJ
ORE
PC
TRC
Fig. 2. Human error risk quantification methodologies (Li et al., 2011).
115
Along with the HEPs for each step, the consequences of human
error must be identified by their level of severity. Consequence
table is often used in conjunction with risk matrix. The conse-
quences of failure to complete a certain evacuation action were
classified into time delay, impact on others, surrounding environ-
ment and health according to four receptor categories. And each
category was divided into 4 grades according to the severity. The
consequence table developed by DiMattia (Khan, Amyotte, &
DiMattia, 2006) was referenced here. The use of consequence ta-
ble would involve assigning a severity level to each of the four
consequence categories for each evacuation action. Literature data
and expert judgment can be combined to estimate the possible
consequences and assign the severity values.
2.3. Risk reduction techniques
Risk reduction is the final stage of the framework. At this stage,
appropriate measures should be taken for high-risk operations
identified in risk matrix according to its failure mode to reduce the
probability of risk occurrence or mitigate the severity of its con-
sequences. There are three aspects of work during this stage, i.e.,
determination of the level of risk reduction required, safety barriers
identification and reliability analysis, and risk re-evaluation. Many
human reliability analysis (HRA) techniques have within them a
basic risk reduction mechanism. However, HRA techniques often do
not have comprehensive or user friendly risk reduction
mechanisms.
Layer of protection analysis (LOPA), conceived and promoted by
the Center for Chemical Process Safety (CCPS) in the United State,
was introduced to determine the necessary safety integrity levels
(SILs) for the automated safety functions in production facilities in
the chemical industry in order to meet the international standards
such as International Electro technical Commission's (IEC) 61511for
control systems on computer controlled facilities in the process
industry (CCPS, 2001). The more recently proposed ARAMIS is a
rigorous methodology based on experience and general reliability
data of safety system. It has several modules and is able to
accommodate LOPA (Gowland, 2006). ARAMIS uses safety barriers
to prevent an unsafe scenario from progressing. The safety barriers
are classified into three categories, i.e., active and passive safety
barriers and those based on human behavior. LC is introduced to
characterize the reliability of safety barriers and approaches to
determine the LC value for different types of safety barriers are
given (Andersen et al., 2004).
The scope of the ARAMIS methodology is wider than LOPA. The
using of the tools which are available within ARAMIS can make the
task of risk reduction analysis easier and results in greater
The Third Generation
ATHEANA
CES
CAHR
COSIMO
CREAM
DREAMS
HDT
OPSIM
MDTA
MIDAS
IDAC
116 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123
Success Success
safety sub-barrier
Organization
Group safety
sub-barrier
Hazard
Fail
Fig. 3. Relationship between human safety sub-barriers.
consistency. Deacon made some modifications to ARAMIS, such as
using HEPs instead of frequencies of incidents in risk graph and
bowetie diagram, and used it in his study on offshore emergency
(Deacon, Amyotte, & Khan, 2010). The modified risk graph and
bowetie diagram were selected in this paper to determine the
requirement for safety barriers, potential available safety barriers
as well as their effectiveness.
A new method was proposed in this paper to determine the LC
of human safety barrier, which will be detailed in the third section.
3. Evaluation of human safety barriers
In the ARAMIS methodology, it has been decided to associate
with human actions a generic probability of failure on demand
(PFD), which is derived at an equivalent LC (Andersen et al., 2004).
This is a method based on historical data. The LC derived from this
method may represent the effectiveness of safety barriers to a
certain extent, but it cannot reflect the actual performance of new
measures adopted, since the use of historical data does not un-
derline the efforts made by the industrialists on their specific site
(Duijm & Goossens, 2006). Deacon et al. (2010) recommended
some safety measures for his human safety barrier (training and
procedure). However, he chose ARAMIS methodology to obtain the
LC of human safety barrier. The relationship between safety mea-
sures and the LC of human safety barrier was not considered, which
is exactly what the newly proposed method will deal with.
Human safety barrier consists of different safety measures
against human actions. In the process of coal production, human
behavior exists at three levels: individual, group and organiza-
tional. Therefore, safety measures against human behavior can be
divided into individual safety measures, group safety measures and
organizational safety measures accordingly. Based on this, Chuming
Mi analyzed the mechanism of human errors in coal mine and
proposed a tertiary prevention framework for the analysis of the
mechanism of human caused coal mine accident (Mi, 2010).
Baoping Cai described human errors as human factor barrier failure
(HFBF), which consists of three categories, i.e., individual factor
barrier failure (IFBF), organizational factor barrier failure (OFBF)
and group factor barrier failure (GFBF) (Cai et al., 2013).
The LC of human safety barrier depends on the effectiveness of
related safety measures. However, the effectiveness of different
measures and their effect on success probability are distinct. The
following effort needs to relate safety measures with the LC of
human safety barrier. Duijm proposed a methodology using safety
management audit assessments and safety culture questionnaire
results to estimate the reductions in the reliability of safety barriers
in major hazard plants (Duijm & Goossens, 2006). Scho € nbeck
researched the effect of human and organizational factors on the
performance and reliability in the operational phase of safety
Safe
Success
Individual safety
sub-barrier
Fail Fail
Accident
instrumented systems by selecting eight security factors (SIFs), and
determining their ratings and weights (Schonbeck, Rausand, &
Rouvroye, 2010). Aven believed that technical, human, opera-
tional, as well as organizational factors influence the accident se-
quences. He presented a method (called BORA-Release) to analyze
the effect of safety barriers to prevent hydrocarbon releases, and
how platform specific conditions of technical, human, operational,
and organizational Risk Influencing Factors (RIF) influence the
barrier performance (Aven, Sklet, & Vinnem, 2006). These efforts
provided us with inspirations for further research on human safety
barrier and determining its reliability.
LC reflects the reliability of safety barrier. In this paper, human
safety barrier is divided into three sub-barriers as organization
safety sub-barrier, group safety sub-barrier and individual safety
sub-barrier. These sub-barriers are composed of safety measures
specifically for organization, group and individual, respectively. As
they function at different levels, they do not influence each other,
which ensures the independence between the three sub-barriers.
The essence of safety measures constituting human safety sub-
barriers is to improve the organization management, group
deployment and personal capacity. Under ideal conditions, a per-
fect organization, group or individual is infallible. However, in the
actual particular case, organization, group or individual may make a
mistake. Nevertheless, individual mistakes can be remedied by
group cooperation and organizational coordination; group mis-
takes can be controlled within the permissible range of organiza-
tional management; similarly, group and individual capacities can
compensate for imperfect organization. Hence, this paper argues
that as long as there is one human safety sub-barrier succeeds,
accident can be avoided. The accident mentioned here refers to
failing to complete certain evacuation actions. Fig. 3 presents the
relationship between these sub-barriers.
Since the safety sub-barriers are constituted by specific safety
measures, we account that the reliability (LC) of these sub-barriers
is determined by the properties (weights and ratings) of the cor-
responding safety measures. Here we assume that the consolidated
result of PSF weights and ratings represents the reliability (success
likelihood) of the corresponding safety sub-barrier. Then the LC of
the human safety barrier can be obtained using Equation
(1).Weight data were obtained by the G1 method (Guo, 2002) based
Table 2
5-Point Likert scale for safety measure ratings.
Rating Explanation Assigned value
1 Little effect 0.2
2 Limited effect 0.4
3 General effect 0.6
4 Very effective 0.8
5 Extremely effective 1.0
 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123 117

Table 3 physical safety barriers, but it is the LC that can be derived directly
Final emergency evacuation procedure. in the our proposed method.
Evacuation phase Evacuation action

Detection 1) Detect the alarm 4. Process and application of the framework

2) Estimate the severity
3) Return process equipment to safe state
4) Listen and followPublic Address (PA) announcement
Escape 5) Evaluate potential egress paths and choose route
6) Move along egress route
7) Assist others if needed
8) Determine whether to continue escape or not
Temporary refuge 9) Evaluate and select possible refuge
10) Check the health and environmental situations
11) Allocate survival resources
12) Send out SOS and wait for rescue
This chapter describes the detailed process of the framework. In
the meantime, an application of the framework in coal mine
emergency evacuation was provided to demonstrate the use of the
framework and its effectiveness. First, a generic evacuation proce-
dure and an evacuation scenario were determined. Then, for the
given scenario, HEPs of each evacuation steps were calculated and
the severities of the consequences were identified accordingly.
Finally, step 3 “Return process equipment to safe state” was chosen
as an example for further risk reduction analysis.

on expert judgment, while the evaluation of effectiveness was 4.1. Determination of evacuation procedure and scenario
conducted with a 5-point Likert scale (see Table 2). description

h  X  X  It is necessary to involve specialists in defining evaluation sce-

LCH ¼ integer  log 1  wind Qind 1  worg Qorg narios, specific emergency evacuation procedure and PSFs. There-
 X i fore, the first critical step of this study was to establish an expert
1 worg Qgro team with the appropriate experts. A study group of 20 coal mine
(1) experts was formed, which contained 5 underground technicians, 5
experienced coal mine workers, 5 safety supervisors and 5 rescue
Where, integer [X] ¼ the integer part of X. workers.
A shared feature between the methods proposed in this paper
and the approaches proposed by Scho €nbeck et al. is the use of 4.1.1. Determination of emergency evacuation procedure
expert judgment to obtain the weights and ratings. However, there The first step of risk evaluation was to set up a complete evac-
€ nbeck et al. just treat human
exist three differences. First of all, Scho uation procedure consisting of a series of independent evacuation
and organizational factors as influencing factors of physical safety actions, which should be suitable for all sorts of withdrawals caused
barriers, whereas they are considered as independent safety bar- by different initiators. At first, an evacuation procedure containing
riers in this article. Secondly, Scho €nbeck et al. consider the impact 17 actions was determined on the basis of the six major systems in
of human and organizational factors by selecting relevant safety China's coal mine emergency evacuation (He & Song, 2012) using
influencing factors, while this is done in this article by taking the hierarchical task analysis (HTA). After that, the initial procedure
relevant measures targeted to specific actions. Finally, the calcula- was judged by the experts. Eventually, an emergency evacuation
tion result of weights and ratings in the methods proposed by procedure which included three stages, i.e., detection, escape and
Scho€ nbeck et al. is a correction factor affecting the reliability of temporary refuge, was set up. The procedure is shown in Table 3.

Emergency
Escape phase Temporary refuge phase

5)Evaluate potential egress 9)Evaluate and select

1)Detect the alarm possible refuge
paths and choose route

10)Check the health and

2)Estimate the severity 6)Move along egress route environmental situations

3)Return process equipment 11)Allocate survival

to safe state 7)Assist others if need resources

4)Listen and follow Public 8)Determine whether to 12)Send out SOS and wait
Address (PA) announcement continue escape or not for rescue

Detection phase No
Possible?

Yes

Successful escape

Fig. 4. Flowchart of emergency evacuation.

118 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123

Table 4 probability of each action in the evacuation procedure differs

Scenario description. accordingly. And consequence severity of failure is also affected.
Scenario factor Detailed description Therefore, it is necessary to give a detailed description of the sce-
1) Initiator Gas explosion
nario. The HEPI muster ranking questionnaire (Khan et al., 2006)
2) Consequences Gas explosion, fire, was applied in this study to make a detailed description of the
exports collapse, delay scenarios. An emergency evacuation caused by gas explosion was
in evacuation, loss of life chosen as the scenario, which is described in Table 4.
3) Weather at the time Raining and winding
of evacuation
4) Time of day for Night 4.2. Risk assessment
evacuation
5) Staff underground Coal mine workers, technicians
6) Experience of staff 6 months to 5 years, part of the
Risk of the evacuation depends on both the failure probability of
underground workers don't have experience the evacuation and its potential consequences. Therefore, risk
of emergency evacuation assessment includes two aspects: (1) estimation of the risk possi-
7) Familiarity with the job Routine task that is familiar bility and (2) determination of the consequences of the risk and its
8) Job complexity Complex but procedural
severity. Calculation of the failure probability for each action was
9) Level of criticality of Job interruption will escalate
the job evacuation initiator conducted using SLIM. And consequence categories and their
10) Location of the Some distance, egress route might severity were determined by consequence table. Finally, risk
individual be affected by the event probability and consequence severity were combined in risk matrix
11) Number of people About 100 to analyze whether the risk is acceptable.
underground

4.2.1. HEP calculation

Fig. 4 shows that workers should try to escape as soon as they
detect the alarm; if the export is stuck because of road collapse, etc.,
they should evacuate to temporary shelters and await rescue.
4.1.2. Scenario description
Different initiators and specific scenarios have different in-
fluences on weights and ratings of PSFs. Thus, the success
Select the expert panel
The calculation of HEP in the method of SLIM is based on the
concept of PSFs, which hypothesizes that human's unsafe behavior
is influenced by the factors in the scenario (Li, Jiang, Sun, Gong, &
Xie, 2012). The combined effect of all the factors can be repre-
sented by HEP. In SLIM method, each factor is associated with
success likelihood index (SLI) by its weight and rating, and then the
HEP can be obtained by the related fitting formula. The general
process of calculating HEP quantitatively using SLIM is illustrated in
Fig. 5 and will be described in the following paragraphs.

Table 5
PSF descriptions.
Define scenario and task PSF Explanation

Stress (St) PSF that affects the completion of

actions as quickly as possible and
the efficiency and success probability
Elicit PSFs of actions, which are prompted by the
threat of the emergency situation.
Complexity (Cp) PSF that affects an additional need
of human work to complete a task
Determine PSF weight successfully because of intricacy of
and rating for each action the action and much more sub-tasks.
Training (Tr) PSF that represents an instinctive
reaction to danger which shows an
effective performance to execute the
Consistency analysis necessary actions through training and
accident drills, which, however, might
cause an extra stress because of the lack
of knowledge of inexperienced danger.
Calculate SLI for each Experience (Ep) PSF that represents some process mode
action from working experience and real accident
experiences which needs an individual judgment
based on observation of the scene situation or
Convert SLI into POS, emergency characteristics, which may not be as
efficient as skills but more effective and applicable
then HEP
and somewhat mitigate the stress of action.
Incident Factors (IF) PSF that covers the description of event initiator
such as type, initial scale, duration, initial location,

Are all actions No instantaneous scope and potential secondary

disasters, which affects the probability of success
evaluated? and individuals' action mode.
Surroundings (Sd) PSF that includes all the physical parameters such
Yes as poisonous gases, coal dust, smoke, fire, impact
air flow, fire-heating air pressure, roof caving,
high temperature and oxygen deficit, with an
Document results instantaneous, continuous and dynamic effect,
which affects human health severely along the
evacuation route.
Fig. 5. SLIM application flowchart.
 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123 119

0.35 80

0.3 70
0.25
60
St St
0.2
Weights

Cp 50 Cp

Ratings
0.15
Tr Tr
40
0.1 Ep Ep
0.05 IF 30 IF
0 Sd Sd
20
1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Detection Escape Taking Refuge Detection Escape Taking Refuge
Evacuation actions Evacuation actions
Fig. 6. PSF weights of evacuation actions in the given scenario. Fig. 7. PSF ratings of evacuation actions in the given scenario.

4.2.1.1. PSFs selection and description. PSFs are those parameters
influencing the ability of human beings to complete a given task.
Nine initially proposed PSFs by the authors, i.e., stress, complexity,
training, experience, fatigue and health, knowledge and skills,
safety attitude, incident factors, surroundings, were submitted to
part of the panel members for review and comment. According to
three principles of independence, direct correlation and easy
quantification (Xue, Fan, & Zhang, 2012), the final 6 most relevant
PSFs were obtained with the common consensus of experts. See
Table 5.
4.2.1.2. PSF Weights and ratings. The weight refers to the relative
importance of each PSF in a particular scenario. The weight of the
same PSF for different actions may be different. The pair-wise
comparison method (Lin & Wu, 2010) based on expert judgment
was used to determine the weights of PSF of a particular action for a
given scenario. The consequence of PSF weights is shown in Fig. 6.
PSF ratings range from 0 to 100 with the increment of 10 for each
level, of which 100 stands for the optimal conditions and 0 for the
worst. Experts rated PSFs of each action in the given scenario using
specifically designed questionnaire. Table 6 and Fig. 7 show the
rating scale and rating results respectively.
The elicited PSF weight and rating data were subjected to sta-
tistical analysis to test reasonableness. Intra-class correlation co-
efficient was calculated both for weight and rating data of each
evacuation action. The results indicate that the elicited PSF data are
rationally explainable and show no significant biases arising from
the team of judges that provided the data.
4.2.1.3. HEP calculation. Having obtained the relative importance of
weights and ratings, they are multiplied together for each PSF and
the resulting products are then summed to give the Success Like-
lihood Index (SLI). The SLI will then be related to the probability of
success (POS) using a suggested logarithmic relationship of the
Table 7
a and b values for different SLI.
SLI a b
20e47 0.00736 0.448
45e72 0.00154 0.115
76e88 0.000302 0.0273
form, Log P(POS) ¼ a (SLI) þ b, where a and b are empirically
derived constants (DiMattia, Khan, & Amyotte, 2005).
DiMattia's research result was used to calibrate the SLI. DiMattia
calculated the values of constants a and b covering a range of SLI
values from limited THERP data of Swain and Guttmann (1983) and
data of Kirwan (1994), see the following Table 7 (Xue et al., 2012).
There are some regions of gap and overlap between the three
different value ranges of SLI. DiMattia recommended that the log
POS be estimated based on the more conservative (i.e., lower) SLI
range. Then HEP can be obtained by simply subtracting the POS
from one. The results are shown in Table 8.
4.2.2. Consequence severity analysis
Consequence table was used to determine the consequence
severity in this article. The consequences of failing to complete
certain muster actions were divided into four categories by
DiMattia(2004), including egress ability, other POB, muster initiator
and health. Duo to the similarity between coal mine emergency
evacuation and offshore emergency muster, similar categorization
was adopted in this research (Table 9). Otherwise, the consequence
severities 4 and 5 were amalgamated from the ISO 17776 risk
matrix into severity 4 in order to keep consistent with ARAMIS risk
graph. A severity level was assigned to each of the four conse-
quence categories for every action. And the level of the action was
determined by the highest level of the four categories.
Table 8
Assessor HEP results.

Phase Action HEP value

Table 6
PSF rating scale. Detection 1) Detect the alarm 0.2362
2) Estimate the severity 0.0852
Scale PSFs 3) Return process equipment to safe state 0.0880
4) Listen and follow PA announcement 0.0791
Stress Complexity Training Experience Event Atmospheric
Escape 5) Evaluate potential egress paths and choose route 0.3371
factors factors
6) Move along egress route 0.2640
100 no stress not complex highly very no no effect 7) Assist others if necessary 0.3260
trained experienced effect 8) Determine whether to continue escape or not 0.2884
50 some somewhat some somewhat some some effect Temporary 9) Evaluate and select possible refuge 0.3108
stress complex training experienced effect refuge 10) Check the health and environmental situations 0.0893
0 highly very complex no no experience large large effect 11) Allocate survival resources 0.2375
stressed training effect 12) Send out SOS and wait for rescue 0.2734
120 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123

Table 9
Consequence categories and severity descriptions.

Consequence category

Severity Time delay Impact on others Surrounding environment Health

Low Minor delay in escape Lead minor delay in Raise environment risk to a level which No injury
(1) from mine escape time to others causes a minor delay in escape
Medium Significant delay in Lead significant delay Raise environment risk to a level which Minor injury
(2) escape from mine in escape time to others causes a significant delay in escape
High Cannot escape from Prevent others to escape Raise environment risk to a level which Significant injury
(3) mine, need to refuge from mine, need to refuge cannot escape from mine
underground underground
Critical Cannot reach any safe Prevent others to escape Raise environment risk to a level which Loss of life
(4) area underground from hazard cannot escape from hazard

The severity of each action was first assigned by the author
based on empirical data (Jia, 2012; Wang, 2004) and then submit-
ted to experts for review and comment in the form of question-
naire. The final results are shown in Table 10 which contains the
results of 4 different consequences severities, of which the highest
was chosen as the final consequences severity.
4.2.3. Risk matrix
ISO 17776 uses the frequency of occurrence and consequence
severity as factors of risk matrix. Deacon modified the risk matrix
by replacing the frequency of occurrence with HEP and adjusting
the severity level, and developed a modified risk matrix for the
emergency evacuation of offshore oil platforms (Fig. 8). The
modified risk matrix is divided into three areas. The white areas
require no mitigating measures, the light gray areas require risk
reduction measures and the dark gray area are not acceptable
(Deacon et al., 2010). As the consequence severity level is assigned,
combined with the HEP, risk of each action can be determined to
decide whether there is a need to reduce it or not. Combined with
the safe function of each action, it is possible to take safety
measures.
The HEP for action 3“Return process equipment to safe state”
was 0.088 and the consequence severity was 4. Since the risk is
unacceptable, measures must be taken to improve this action.
4.3. Risk reduction
mitigation barriers based on how they function. Prevention barriers
prevent the occurrence of the critical events by cutting off the path
from the critical events to its failure mode. Mitigation barriers
reduce the severity of the critical event by restricting or controlling
the result of the events (Cameron & Raman, 2005). Safety barriers
can also be divided into active safety barriers, passive safety bar-
riers and human safety barriers (Sklet, 2006). The reliability of
safety barriers can be measured by LC (level of confidence). After
the safety barriers are selected, LC should be assigned to them first.
The methods to determine the LC of safety barriers differ for
different kinds of safety barriers. The LCs of active and passive
barriers were determined using the method mentioned in ARAMIS
(Andersen et al., 2004). And the LC of human safety barriers was
calculated by the method described in section three.
Automatic shut-down mechanism (ASD) as an active barrier and
human safety barriers are available to action 3. ASD has the sub-
systems of detection, treatment and action. Based on the analysis of
the ARAMIS user guide, the LC of ASD equals the lowest LC of the
shut-down mechanism's subsystems. Therefore, the overall LC was
assigned to a value of 1 (Deacon et al., 2010).
For the action of “Return process equipment to safe state”, safety
measures for the human safety barriers were determined from
individual, group and organizational levels. Based on the method
proposed in Section 3, the LC of action “Return process equipment
to safe state” was calculated. The LC of the action equals 1. See
Table 11 for details.

4.3.1. Safety barriers 4.3.2. Determination of the required LC

Safety barriers are the specific measures to achieve safety A minimum acceptable LC for the safety function of the critical
functions. They can be divided into prevention barriers and event can be determined by risk graph (De Dianous & Fievez, 2006).
Deacon replaced the frequency of the event occurrence with HEP
Table 10
and adjusted the range of HEP in the risk graph just like what he did
Results of consequences severities.
to risk matrix to make it correspond with the previously estab-
Action Time Affect Environment Health Severity lished risk matrix. Fig. 9 shows the modified risk graph. Note that
delay others
an LC of ‘a’ indicates that there are no safety requirements for the
1) Detect the alarm 3 2 2 2 3 barriers. An LC of ‘-’indicates that there are no additional safety
2) Estimate the severity 3 2 2 2 3 requirements for the muster step. The risk graph is composed of
3) Return process 3 4 3 3 4
equipment to safe state
four variables: Consequence severity (C), frequency of exposure to
4) Listen and follow PA 2 1 3 3 3 risk (F), potential to avoid damage (D) and human error probability
announcement (HEP). The variables F and D are determined using a combination of
5) Evaluate potential egress 4 2 2 4 4 expert judgment and incident reports. After determining these
paths and choose route
variables, the required LC is found.
6) Move along egress route 3 2 2 4 4
7) Assist others if necessary 2 4 1 2 4
8) Determine whether to 3 3 1 4 4 Probability of Consequence severity
continue escape or not human errors Low (1) Medium (2) High (3) Critical (4)
9) Evaluate and select 3 3 1 4 4
possible refuge A: 0.001~0.01 1A 2A 3A 4A
10) Check the health and 1 1 1 4 4 B: 0.01~0.1 1B 2B 3B 4B
environmental situations
11) Allocate survival 2 2 1 2 2 C: 0.1~0.5 1C 2C 3C 4C
resources D: 0.5~1 1D 2D 3D 4D
12) Send out SOS and wait 2 2 2 4 4
for rescue
Fig. 8. Risk matrix (Deacon et al., 2010).
 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123 121

Table 11
Weights and ratings of measures for Return process equipment to safe state.

Action Safety sub-barrier Safety measure Weight Rating

Return process Individual 1) Regular skills testing to restrict 0.34 0.80

equipment unqualified workers to work
to safe state underground
2) Training of workers to let them 0.38 0.80
master the skills of “Return process
equipment to safe state”
3) Study the influence of the panic 0.28 0.60
in emergency situations on miners'
behavior
Group 1) Difficult job done by the team 0.25 0.60
together
2) Group the inexperienced and the 0.22 0.60
experienced in a team within the time prescribed
3) Strengthen team communication 0.27 0.60
4) Pre-job safety discussions within the team 0.26 0.60
Organization 1) Enlisting feedback after training 0.17 0.60
2) Allocate staff with two-way wireless communication 0.21 0.80
devices to ensure communication with the central
control room when needed
3) Limit operations carried out in bad weather 0.15 0.60
4) Identification of new personnel with different colored clothes 0.11 0.40
5) Location board in control room identifying work locations 0.17 0.60
and personnel
6) Training of experienced personnel to assist others as identified 0.19 0.80

Human Error Probability

0.1-1 0.01-0.1 0.001-0.01 <0.001

1 2 3 4

P1 P2 P3 P4
C1 X1

D1 X2
F1
C2 D2 X3
risk F2 D1
analysis C3 D2 X4
F1
D1
F2
C4 F1 D2 X5
D1
F2
D2 X6

Fig. 9. Risk graph (Deacon et al., 2010).

Since HEP and C had already been determined in early study, F
and D should be determined. ARAMIS stipulates that:
Frequency of exposition of the targets during the operation:
C F1, for the studied operation, targets are few exposed to the
risk (less than 10% of the duration of the operation);
C F2, for the studied operation, targets are very exposed to the
risk (more than 10% of the duration of the operation).
Possibility to avoid damage, by intervention or evacuation:
C D2, in the other cases.
The scope of this work is limited to coal mine emergency
evacuation. As China's coal mine accidents occur quite frequently, a
value of 2 was given for F. The variable D is determined by accident
investigation report. For example, action 3 has a consequence
Table 12
Required LC evaluation.

Step C F D HEP Required LC

C D1, long kinetic and intervention/evacuation clearly defined
and personnel warmed that safety barriers are not efficient; 3 4 2 2 0.088 3
122 L. Wang et al. / Journal of Loss Prevention in the Process Industries 30 (2014) 113e123
No
More
Late
Training
Critical Event:
LC=1
Fail Step 6
Other than Probability=0.088×10-1=0.0088
Part of
Before/After
Fig. 10. Bowetie diagram with safety barriers for evacuation step 3.
severity of 4. Accident reports show that emergency evacuation
caused by gas explosion leaves little time for decision-making, it
could be imagined that without “Return process equipment to safe
state” it will cause greater loss. Therefore, a value of 2 was chosen
for D. The required LC is shown in Table 12.
4.3.3. Analysis of safety barriers' effectiveness
Boweties illustrate a fault tree attached to an event tree for a
common critical event. Normally, the probability of occurrence of
each failure mode in the fault tree is calculated. Then, the combi-
nation of these probabilities determines the probability of occur-
rence of critical events. But for coal mine emergency evacuation,
the probability of the occurrence of each failure mode is unknown
and there is not enough data to calculate them. However, the
probability of the occurrence of critical events (human error) can be
obtained by expert judgment. Deacon's recommendation, using the
HEP obtained by expert judgment (Deacon et al., 2010), was
adopted in this article. This modification demands that the applied
prevention barriers must be appropriate for all failure modes.
During the re-calculation of the occurrence probability of critical
event, the success of the prevention barriers needs to be incorpo-
rated and HEP is altered by a factor of 10-LC. The possible conse-
quences of critical events are shown as the event tree branches. The
success of the mitigation barriers will reduce the consequence to a
lower level (Cameron & Raman, 2005). The probability of the lower
consequence is altered by a factor of 1e10-LC. The probability of the
original consequence is altered by a factor of 10-LC (De Dianous &
Fievez, 2006). After the bowetie analysis, the new risk value is
obtained and needs to be re-incorporated into the risk graph to
determine whether the risk is adequate and whether it must be
further reduced or not. This can be done by applying new inde-
pendent safety measures or enhancing the LC of existing measures.
Bowetie was constructed for action 3 to analyze the influence of
safety barrier on HEP (Fig. 10).
5. Conclusions
A framework for human error risk analysis of coal mine emer-
gency evacuation in China has been developed and a new method
to evaluate the reliability of human safety barriers is proposed in
this paper. The framework contains a generic evacuation procedure
which is consistent with the actual situation of coal mine produc-
tion in China and appropriate to different causes. The SLIM method
based on expert judgment and consequence table is used to
quantify the HEP and evaluate the consequence severity respec-
tively. Risk matrix is used to identify the serious action which
cannot be tolerable. Then the bowetie diagram and risk graph are
adopted to select and analyze safety barriers, allowing re-
evaluation of the acceptability of risk. Human safety barriers are
divided into individual safety sub-barrier, group safety sub-barrier
and organization safety sub-barrier, each containing a number of
specific safety measures. G1 method is selected to determine the
Consequence 3
Probability=0.0088×(1-10-1)=8×10-3
Down Mechanism
Automatic Shut
LC=1
Consequence 3
Probability=0.0088×10-1=8.8×10-4
weights of each measure and the ratings are obtained with a 5-
point Likert scale. Then the LC of human safety barriers can be
calculated.
The effort of this paper fills the gap of research on human factors
in coal mine emergency evacuation in China and provides a
convenient tool for risk analysis. By improving the accuracy of risk
prediction and taking appropriate measures, the probability of the
risk occurring can be lowered and the severity of the consequence
can be controlled. Thus the miners' survival rate is improved when
accident occurs. Although the framework is developed for coal
mine emergency evacuation, it is also appropriate to those high-
risk industries which may need emergency escape.
In order to further improve the framework, the related research
can be made from the following aspects:
1) Other expert judgment techniques could be used to compare
with the HEP estimates obtained from the current approach
(SLIM), such as Bayesian Network, to represent relationships
between human factors.
2) The LC of active safety barriers considered in this paper is the
design LC, which is the maximum under ideal conditions.
However, management factors will reduce the design LC. There
is a need to study the effect of management factors on active
safety barriers.
3) Further researched of the evaluation of human safety barriers
are needed to ensure the completeness of safety measures
against human actions. Mathematical models based on more
rigorous theory that represents the relationship between spe-
cific measures and the LC of human safety barriers are essential.
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