基于模糊层次分析法的组织因素影响度识别

基于模糊层次分析理论,构建影响系统安全的组织因素模型,确定影响系统安全的组织因素指标体系,利用因素相对影响度R、因素总体影响度C和因素重要度I来表征组织因素对系统安全的影响程度。采用该因素影响度方法分析了组织因素对某核电站系统安全的影响,发现监督、安全文化培训、领导对安全的态度、程序的完备性、部门间的交流与反馈、协调、个人的意识和态度、岗前技能培训、部门内的交流与反馈是对核电站运行安全影响最大的组织因素。     

地铁行车调度系统人误影响因素识别及评定研究

为寻找影响地铁行车调度系统人误的因素,提出结合SHEL模型与层次分析法(AHP)的人-机-环系统人误影响因素识别及评定技术。通过扩展SHEL模型到人-任务、人-列车、人-人机界面、人-环境、人-线路、人-人、人-客观其他7个界面,构建人误影响因素分析模型;在对上海地铁54名行车调度员问卷调查的基础上,引以因子分析法识别出19项人误影响因素;并通过搭建人误影响因素层次结构模型及运用AHP法实现对人误影响因素的评定。结果表明,影响行车调度人误的因素中权重居前5位的分别为客流问题、行车密度、问题列车数、人机界面可支持性及人机界面布局合理性。因此,在客观运营条件不能改变的情况下,可以用改善人机界面条件来减少人误的发生。     

地铁行车调度系统人误影响因素识别及评定研究北大核心CSCD

为寻找影响地铁行车调度系统人误的因素,提出结合SHEL模型与层次分析法(AHP)的人-机-环系统人误影响因素识别及评定技术。通过扩展SHEL模型到人-任务、人-列车、人-人机界面、人-环境、人-线路、人-人、人-客观其他7个界面,构建人误影响因素分析模型;在对上海地铁54名行车调度员问卷调查的基础上,引以因子分析法识别出19项人误影响因素;并通过搭建人误影响因素层次结构模型及运用AHP法实现对人误影响因素的评定。结果表明,影响行车调度人误的因素中权重居前5位的分别为客流问题、行车密度、问题列车数、人机界面可支持性及人机界面布局合理性。因此,在客观运营条件不能改变的情况下,可以用改善人机界面条件来减少人误的发生。     

基于熵权-HDT的航空器维修人误概率确定

人误是造成民用航空维修差错的主要因素。为确定不同情境下人误发生概率,结合某维修基地具体情况,采用熵权法确定主要的影响因子,并基于全决策树法分析主要影响因子对航空器维修人误概率的影响程度。计算结果显示,该维修基地人因可靠性的主要影响因子包括航空器维修人员的安全态度、技能、沟通、工作环境、压力以及工段长领导能力。根据各主要影响因子的不同品质描述等级组合,确定该情境下航空器维修人员的人误概率。鉴于该维修基地人因可靠性影响最明显的因子是"沟通",提出信息及时交流、明确沟通重要性等解决措施。     

空中交通管制团队人误的分类及致因研究

复杂社会技术系统通常以团队方式运行,认识与预防团队人误是控制安全风险的重要途径。研究采用威胁与差错管理(TEM)的研究框架,以某空管运行自愿报告系统2004年全年数据为样本源,分析团队人误的流程与致因,统计发现团队人误占总体空管人误的31%。团队发现和指出错误后仍不能有效纠正错误的比例达到8%。根据样本统计并结合典型团队人误的案例,确认了空管团队人误的主要类型和分布情况以及团队行为促成因素(PSF)的框架及重要性排序,其中缺乏交流是团队人误的最常见PSF,报告样本量出现率达47.1%。最后,从组织文化建设、团队管理、标准操作程序、培训等方面提出了减少团队人误的建议。     

基于AHP-SLIM的航空器维修人误概率确定

人误是造成民用航空维修差错的主要因素。由于缺少实际的数据,对航空维修行业人为失误发生的规律进行研究是必要的,但是规律研究主要依赖于该领域专家的判断,很难确保一致性。为了克服这个困难得到更加准确的评估,本文将层次分析法同成功似然函数结合起来估计造成飞机/发动机/附件损坏的人误概率。该方法确定了航空器维修人员的安全态度、知识和技能、计划和监管、信息沟通等因素,对人误的影响程度以及飞机/发动机/附件损坏中常见人误的发生概率。计算结果表明,操作/试验时最容易发生飞机/发动机/附件损坏,并且提出加强组织和监管、严格按章办事等解决措施。     

核电站安全相关的组织因素分析

随着国内核电站建设的迅速发展,核电站安全问题越来越受到广泛关注。核电站安全从硬件评价到人因可靠性分析,组织因素在核电站安全中的作用越来越受到重视。分析了与核电安全相关的组织因素分类原则,提出了核电安全组织因素,为核电站组织安全管理提供决策依据。     

高风险系统组织因素分类与绩效评价

在收集以组织绩效评价、人的可靠性和人误分析为目的的两类组织因素分类的基础上,结合问卷调查,并依据建立的概念上的组织因素分类框架,从组织的目标和战略、组织结构、资源、规程、管理功能、培训、交流、组织文化等方面确立组织因素分类指标,基本克服了传统的组织因素分类缺陷。同时,依据组织因素的分类,考虑到组织绩效评价的复杂性和不确定性,采用模糊决策方法对某组织的绩效进行评价,识别出该组织现存的主要缺陷:组织管理方面的问题以及组织的结构设计不太合理等问题。     

人误因素树构建技术研究

运用人误因素辨识多视图法进行因素辨识,建立了详细的因素辨识表;把人的行为分为5个阶段,即系统状态监测阶段,目标分析阶段,方案确定阶段和行为执行阶段.分别分析各个阶段可能的人误原因及模式;以组织视图为例,根据因素辨识和人误原因及模式分析结果,阐述人误因素树的构建过程,最终得到了1个完整的人误因素树.     

复杂系统中人误原因因素的层次分析法

介绍和评析了人误分析历史上有重要影响的几种人误原因因素分类方法:传统人因分类法、信息处理分类法和认知系统工程分类法.基于认知可靠性及失误分析方法(CREAM)的人误原因因素分类,运用层次分析法(AHP)基本原理,建立了大规模复杂人-机系统人误原因因素层次结构模型及相应的AHP程序,并以JCO公司超临界事故为实例进行了分析.分析和应用结果表明,本文所建立的人误原因因素层次结构模型及AHP程序能够辨识出大规模复杂人-机系统中人误的主要原因因素,进而寻找出最优预防方案,对预防和减少此类人误事故的发生有积极意义.     

核电厂人因事故预防的定量化决策

人因事故的分析与预防是核电厂安全运行和管理的重要内容。笔者提出的系统安全性层次分析法主要从两种角度考虑系统的安全性:专家能力权值和安全性矩阵的建立。采用专家判断矩阵确定事故原因对系统安全性的重要度排序。举例某核电厂事故定量分析进行说明,在对事故进行原因分析基础上,构建事故影响因素层次模型,利用层次分析法分析得出事故原因重要度排序由高到低依次为组织管理、操作人员、人机界面、培训与设备状态,并据此提出了相应的预防与改进措施,为安全性要求较高的复杂工业系统提供事故预防的定量化决策依据。     

On the operator action analysis to reduce operational risk in research reactors

Human errors during operation and the resulting increase in operational risk are major concerns for nuclear reactors, just as they are for all industries. Additionally, human reliability analysis together with probabilistic risk analysis is a key element in reducing operational risk. The purpose of this paper is to analyze human reliability using appropriate methods for the probabilistic representation and calculation of human error to be used alongside probabilistic risk analysis in order to reduce the operational risk of the reactor operation. We present a technique for human error rate prediction and standardized plant analysis risk. Human reliability methods have been utilized to quantify different categories of human errors, which have been applied extensively to nuclear power plants. The Tehran research reactor is selected here as a case study, and after consultation with reactor operators and engineers human errors have been identified and adequate performance shaping factors assigned in order to calculate accurate probabilities of human failure.     

Ergodynamics and Hybrid Intelligence Systems in the Reliability of Power Plant Operators

Based on ergodynamics and the hybrid intelligence theory, an analysis of the nuclear power plant operator’s performance is given at the levels of strategies, tactics, and actions. Special attention is paid to the strategies used in the course of severe accidents at nuclear power plants. Data from Ukrainian and Russian power plants and training centres and from accidents around the world were collected and processed. It is shown that in an emergency it is essential for the human operator to be flexible. This flexibility includes two main training and personal factors: a large set of strategies and tactics the operator manages to use, and quick transformations between the strategies (tactics). It was also found that some emergency tasks are too complicated: They require simultaneous use of different strategies, with time strictly limited by nuclear power plant dynamics. Those tasks cannot be successfully solved by any individual operator. Hybrid intelligence systems involving different specialists should be used in those cases in order to avoid failures in emergency problem solving.     

核电厂主控室人机界面评价实验研究

基于以人为中心的人机交互设计和评估的思想,结合国内核电厂的实际情况,确定一些重要的核电厂主控室人机界面评估因素,并划分核电厂主控室人机界面各组成部分的评价指标与评价层次,建立了客观的评价指标体系,为核电厂主控室人机界面综合评价奠定了基础。运用模糊数学的方法,建立核电厂主控室人机界面定量评价模型,对核电厂主控室人机界面进行较为客观的综合评价。通过对核电厂操纵员问卷调查的形式进行实验验证,从而实现了定性评价与定量评价的一致性。研究表明,该方法应用于核电厂主控室人机界面评价是一种有效的方法。     

Team crystallization (SIO2): Dynamic model of team effectiveness evaluation under the dynamic and tactical environment at nuclear installation

Accident management activities at nuclear power plants require concurrent communication, information sharing, team based decision-making and collective actions under tactical and dynamic environments. Team effectiveness under such environments can be characterized as the performance of team situation awareness with hierarchically distributed information and knowledge susceptible to organizational characteristics and communication quality. This paper proposes a team performance model, called a team crystallization model comprising of four elements: state, information, organization, and orientation and its quantification method using a communication process model based on a receding horizon control approach. The team crystallization model is a holistic approach for evaluating team effectiveness in conjunction with team situation awareness considering physical system dynamics and team behavioural dynamics for a tactical and dynamic task at a nuclear power plant. This model provides a systematic measure to evaluate time-dependent team effectiveness or performance affected by multi-agents such as plant states, communication quality in terms of transferring situation-specific information and strategies for achieving the team task goal at a given time, and organizational factors. To demonstrate the applicability of the proposed model and its quantification method, a case study was carried out using the data obtained from a full-scope power plant simulator for 1000 MW(e) pressurized water reactors with four on-the-job operating groups and one expert group who knew accident sequences.     

核电厂人因及组织行政管理安全审查体系

定期安全审查 (PSR)是国际原子能机构 (IAEA)近年推广的一种新的核电厂安全审查方式 ,它强调系统性、全面性和关键性。人因安全因素 (HF)、组织机构和行政管理安全因素 (OA)是PSR的重要组成部分 ,也是PSR中审查难度较大的部分之一。其难点主要在于如何用有限的评审指标去刻画出最能表征人因、OA对核电厂安全运行最具影响的特征因子 ,建立起科学的、系统化的审查体系 ,且该体系还需具有较强的可操作性。基于上述认识 ,笔者建立了核电厂人因及组织行政管理安全审查体系 ,它包含安全目标与方针、人员配备与资格、组织机构与管理、配置控制、培训、职业健康、运行经验反馈、质量保证、人 -机接口、遵章守法等 10类 19个要素。同时介绍了其评审指标、审查内容、审查方法和程序等。该体系已应用于秦山核电厂。     

CREAM-based communication error analysis method (CEAM) for nuclear power plant operators’ communication

Communication error has been considered a primary cause of many incidents and accidents in the nuclear industry. In order to prevent these accidents, a method for the analysis of such communication errors is proposed here. This paper presents a qualitative and a quantitative method to analyze communication errors. The qualitative method focuses on finding a root cause of the communication error and predicting the type of communication error which could happen in nuclear power plants. We develop context conditions and antecedent-consequent links of influential factors related to communication errors. The quantitative analysis method focuses on estimating the probability of communication errors. To accomplish the quantification of communication errors, the Cognitive Speaking Process (CSP) is defined and a method to estimate the weighting factors and the probability is suggested. Finally, case studies conducted to validate the applicability of the proposed methods are detailed. From the results, we can foresee the effects of given plant conditions on communication errors and reduce the error occurrences.     

复杂工业系统中人因失误根本原因分析

在现代大规模复杂人 -机 -环境系统中 ,人因失误诱发的故障或事件呈上升趋势。人因事件的根本原因分析 ,对于防范复杂系统中事故的发生是非常必要的。人因事件根本原因的分析包括 :需要分析的人因事件的确定 ;对事实进行调查 ,分析调查结果 ;确定根本原因 ;制定纠正措施 ;完成最终报告。人因事件的分析最终需要找出失效屏障并提出修补的方法 ,笔者采用事件与原因因子分析技术来进行分析。在分析过程中 ,需要绘出事件和原因因子图 (E&CF图 ) ,而E&CF图可以显示出从开始到结束全过程中事件发生的正确次序 ,通常包括失效屏障 ,预先存在的条件、次级事件、不恰当的动作和形成事件的原因因子。形成人因事件的原因因子在复杂工业系统中 ,可以分成 12个部分。笔者给出了核电厂蒸汽发生器 (SG)主给水阀门泄漏的人因事件的分析实例 ,确认了该实例中失效的屏障和事件的根本原因并提出了纠正措施。     

An integrated framework to the predictive error analysis in emergency situation

This paper introduces an analysis framework and procedure to predictively analyze human errors in performing emergency tasks, which are mostly composed of cognitive activities, in nuclear power plants. The framework focuses on the cognitive errors and provides a new perspective in the utilization of context factors into cognitive error prediction. The basic viewpoint on the occurrence of cognitive error taken in this paper is that the cognitive function failures occur from the mismatch between operator's cognitive capability and the requirements of a given task and situational condition. In accordance with this viewpoint, performance influencing factors that influence the occurrence of human errors are classified into three groups, i.e. Performance Assisting Factors (PAF), Task Characteristic Factors (TCF), and Situational Factors (SF). This classification helps analysts view the overall task context in an integrative way by considering the level of PAF with the requirements of TCF and SF to predict the possibility of cognitive function failures. Further, it enables analysts to draw specific error reduction strategies. The framework suggested was applied to the analysis of cognitive error potential for the bleed and feed operation of emergency tasks in nuclear power plants.