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。     

一种基于贝叶斯网络的机务维修差错调查模型算法

提出一种基于贝叶斯网络的机务维修差错调查模型算法,根据已经建立的机务人为诱因导致事故/事故征候模型,利用贝叶斯原理编程实现了该算法。利用该算法对中国民航飞行学院2001-2011年的机务人为有引导的事故/事故征候依次进行分析并验证,得到了相应的事故诱因概率排序。该算法克服了样本空间不足,在事故发生以后能够在引入其他证据的情况下根据以前的经验概率得到新的事故诱因概率排序,为民航机务维修差错调查提供了可靠的技术支持。     

基于TEM模型的民航不安全事件关联规则挖掘与分析*

为了预防民航不安全事件的发生,应用机组威胁与差错管理（TEM）模型分析2014—2020年民航事故/征候的航空安全报告资料,提取事件里存在于民航运行风险中潜在的情况、威胁、机组差错等因素,通过改进的关联规则方法挖掘其中的关联关系,包括挖掘与事件严重程度有关的因素,找到TEM模型中的关键因素和影响航空器结束状态的致因因素,并进行关联网络图分析。研究结果表明:手动操纵/飞行控制差错、缺少/不足的飞行培训和安全管理、飞行员之间沟通差错与程序执行错误是造成事故/征候的显著因素;关联规则能够有效利用航空安全报告信息,通过定量的方法挖掘事故/征候的特征,找到影响民航不安全事件的强关联因素,为民航安全管理人员提供决策依据。     

New considerations for SIL verification of functional safety fieldbus communication

Safety integrity level (SIL) verification of functional safety fieldbus communication is an essential part of SIL verification of safety instrumented system (SIS), and it requires quantifying residual error probability (RP) and residual error rate of function safety communication. The present quantification method of residual error rate uses RP of cyclic redundancy check (CRC) to approximately replace the total RP of functional safety communication. Since CRC only detects data integrity-related errors and CRC has intrinsically undetected error, some other residual errors are not being considered. This research found some residual errors of the present quantification method. Then, this research presents an extended new approach, which takes the found residual errors into account to determine more comprehensive and reasonable RP and residual error rate. From perspective of the composition of safety message, this research studies RPs of those controlling segments (sequence number, time expectation, etc.) to cover the found residual errors beyond CRC detection coverage, and the influences of insertion/masquerade errors and time window on RP are investigated. The results turn out these residual errors, especially insertion/masquerade errors, may have a great influence on quantification of residual error rate and SIL verification of functional safety communication, and they should be treated seriously.     

An integrated quantitative risk analysis method for natural gas pipeline network

Natural gas industry is developing rapidly, and its accidents are threatening the urban safety. Risk management through quantitative assessment has become an important way to improve the safety performance of the natural gas supply system. In this paper, an integrated quantitative risk analysis method for natural gas pipeline network is proposed. This method is composed of the probability assessment of accidents, the analysis of consequences and the evaluation of risk. It is noteworthy that the consequences analyzed here include those of the outside and inside gas pipelines. The analysis of consequences of the outside pipelines focuses on the individual risk and societal risk caused by different accidents, while those of the inside pipelines concerns about the risk of the economic loss because of the pressure re-distribution. Risk of a sample urban gas pipeline network is analyzed to demonstrate the presented method. The results show that this presented integrated quantitative risk analysis method for natural gas pipeline network can be used in practical application.     

事故前人因失误研究

在安全评价中，人因失误特别是事故后人因失误越来越受到重视；但相对而言，事故前人因失误没有引起足够的重视。本通过对大量核电厂安全分析报告和运行事件报告的考察，系统地阐述了事故前人因失误对系统安全的显影响，并在此基础上，归纳出在核电站开展事故前人因(失误)分析的程序。该程序主要包括系统熟悉，定性分析，筛选，定量计算，与故障树的集成，敏感性分析与不确定性分析，形成分析档等几个步骤。     

基于MAIB事故报告的人为失误灰色关联分析

人为失误作为海上交通事故的主要原因,受到多种因素的影响。为了识别这些影响因素,避免或减少因人为失误导致的海上交通事故,基于96件英国海事调查委员会(MAIB)事故报告,应用熵加权灰色关联分析,分别按船旗国、船舶类型、事故类型计算人为失误与影响因素之间的关联度。结果表明,能力/技能/知识、团队协作、程序和现行规程、设备、交流(内部和外部)和管理/检验/检查是影响人为失误的主要因素。     

基于改进N-K模型的公共建筑火灾风险耦合研究

为了弥补传统N-K模型需要大量统计数据支撑才能应用的局限性,提出了一种改进N-K模型。该模型能在缺少统计数据的情况下,结合层次分析法将事故发生概率替代为风险因素的频度进行风险耦合度计算。将此方法应用于公共建筑火灾风险耦合的研究中,结果表明:耦合风险因素越多,风险值越大;耦合风险因素相同时,建筑因素比设备因素更易造成火灾事故,人员因素比管理因素更易造成火灾事故;主观因素耦合风险比客观因素耦合风险大。分析结果与近些年发生的公共建筑火灾事故比较,关键致因风险及耦合情况与实际总体状况一致,证明了改进N-K模型具有一定理论价值。     

核电厂HRA定性分析

人因可靠性分析(HRA)是核电厂概率安全评价(PSA)的重要组成部分,定性评价对核电厂庞大的数据进行筛选和分析,是HRA的基础和出发点.本文介绍了核电厂HRA定性分析的目的、原则、方法和程序,并以压水堆核电厂蒸汽发生器传热管破裂(SGTR)为具体实例进行说明.     

基于贝叶斯网的交通事故机理分析

针对道路交通事故的形成机理进行定性、定量研究,根据我国道路交通事故记录数据特征,应用贝叶斯网对事故发生概率进行定量分析.引入"驾驶员紧张度"和"道路线形合理度"两个隐节点,建立了事故分析的贝叶斯网多层隐类模型,采用最大似然估计方法确定了模型的边缘概率和条件概率.将贝叶斯网模型应用于国道104二级公路(K1310+000～K1330+000)的事故分析中,运用贝叶斯网分析软件包Netica对其历史事故记录数据进行分析.结果表明: 贝叶斯网不仅可以定量计算某种道路交通状态下的事故发生概率,而且可以找出影响事故概率的关键原因和最不利状态组合(事故概率最大时的道路交通状态).     

基于HFACS的空中相撞事故分析及建议

空中相撞事故往往是由诸多人为差错相互叠加、耦合和作用而导致的,要找出事故的真正诱因,防止类似事故再次发生,难度非常大。为了有效地分析和定位人为差错,以更好地服务于防相撞的管理与决策,提出一种基于人为因素分析分类系统（HFACS）的空中相撞事故分析方法,它按照从显性差错到隐性差错的思路来分析事故的诱因,最终找出组织因素对事故的影响。并利用HFACS对巴西卡欣布上空发生的一起空中相撞事故进行了系统分析。案例分析结果表明,该方法不仅能够找出导致空中相撞事故的人为差错,解释事故发生的原因和过程,而且能够据此提供防止相撞事故发生的安全建议。     

航空人为差错事故/事件分析(ECAR)模型研究

为深入研究航空人为差错事故/事件的影响因素,以人为差错相关理论为基础,对比分析几种典型的人为差错分析模型;通过借鉴ECCAIRS分析框架,并在基元事件分析(EEAM)逻辑和CCAR396部的分类方法基础上,构建航空人为差错事故/事件分析(ECAR)模型,它从事件层、描述层、原因层和组织因素与改进建议层,分析航空事故和不安全事件的人为差错。此外,还将组织因素概念引入该模型。     

Risk assessment tools incorporating human error probabilities in the Japanese small-sized establishment

Although it has been estimated that as many as 80% of all occupational accidents have human errors as a cause, no risk assessment tools incorporating human-related elements have been developed for small companies. Human error probability (HEP) and human error analysis (HEA) have been used for large-scale, safety-critical industries for last three decades, but these tools are not suitable for smaller, more general industries that comprise the majority of accident settings.Here, we describe and verify a risk assessment tool that includes human-related elements for small companies. The tool expands on traditional risk assessment methods, such as matrix, risk graph and numerical scoring method, by adding human-related elements. The tool is easy-to-use in occupational environments, and includes assessments of human behavior and potentially outdated machinery at work place.     

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.     

质子交换膜燃料电池电站多米诺事故概率和风险研究*

为探究氢能电站火灾爆炸事故发展规律,采用多米诺效应对电站进行事故概率和风险研究,建立氢能电站多米诺效应定量风险分析模型。基于设备受损概率模型与多米诺理论基础,提出氢能电站多米诺效应概率计算方法,并将方法运用到实际案例,结合SAFETI软件对具体多米诺事故场景进行定量计算。研究结果表明:氢能电站易发生多米诺事故,考虑一级多米诺效应后人员潜在死亡概率增加56%。研究结果可为制定氢能电站安全防控措施以及降低火灾爆炸事故对人员和设备的危害提供依据。     

系统故障演化过程不连续现象的原因及消除方法研究*

为研究系统故障演化过程中,通过原因事件得到的结果事件发生可能性与直接试验得到的结果事件发生可能性不同的问题,定义系统故障演化过程的不连续现象,研究不连续现象出现的原因和消除方法。根据不连续现象的程度将原因分为3层,第1层是基本的原因事件、结果事件或传递的概率错误造成的不连续;第2层是因素对应错误造成的概率错误;第3层是演化结构不清造成的错误。针对这些错误提出消除方法,基本方法包括试验法、结构分析法和逻辑推理法;第2层次使用空间故障树和因素空间等方法;第3层使用三值逻辑等方法。研究结果表明:导致不连续的原因是演化过程的结构性问题,消除的方法应根据实际情况进行选择和变化。     

On the application of the window of opportunity and complex network to risk analysis of process plants operations during a pandemic

To quantify the pandemic specific impact with respect to the risk related to the chemical industry, a novel risk analysis method is proposed. The method includes three parts. Firstly, the two types of “window of opportunity” (WO) theory is proposed to divide an accident life cycle into two parts. Then, a qualitative risk analysis is conducted based on WO theory to determine possible risk factors, evolution paths and consequences. The third part is a quantitative risk analysis based on a complex network model, integrating two types of WO. The Fuzzy set theory is introduced to calculate the failure probabilities of risk factors and the concept of risk entropy is used to represent the uncertainty. Then the Dijkstra algorithm is used to calculate the shortest path and the corresponding probability of the accident. The proposed method is applied to the SCR denitrition liquid ammonia storage and transportation system. The results show that it is a comprehensive method of quantitative risk analysis and it is applicable to risk analysis during the pandemic.     

Why bad things happen to good people

Accidents in the process industries are extensively investigated to determine root causes, for lessons learned, and many times in search of the “guilty”. Accidents are seldom simple and most accidents have human elements that led to or facilitated the accident. Many times the people involved in these accidents, when considered individually on their merit, would be considered “good” people yet “bad things” (accidents) still occur.Human errors can be classified as individual, group, and organizational. Individual human errors have been addressed in a number of studies and papers. Many of these classify human errors and treat them probabilistically or cognitively. Less has been said regarding the individual psychological/sociological response/interaction mechanisms that might contribute to an industrial accident. These elements also contribute to a lack of situational awareness which often plays a large part in human error. Group and organizational interactions/dynamics can also contribute negatively to situational awareness and to the chain of events of an accident. Organization errors, which are typically latent, can also facilitate an accident and are many times people enabled for personal and business vested interests.This paper will discuss the effect of human error at the practical plant level in contributing to accidents in the process industries from individual, group, and organizational perspective. The discussion will include psychological/sociological response/interaction mechanisms that can contribute to situational awareness and human error. It will also discuss how complexity, veracity, and quantity of available information can affect the human decision-making process leading to mistakes.Accidents are seldom simple and most accidents have a number of elements that led to or facilitated the accident. When looking at individual elements probabilistically, multiplying probabilities together, it is hard to see how an accident could have occurred. A common refrain “That’s double jeopardy and we don’t have to consider that” is essentially a qualitative probabilistic analysis. Yet we have cases of triple, quadruple, n-jeopardy occurring to cause accidents. The paper will discuss the superimposition of causes and a similar concept of functional resonance in causing accidents.     

基于最优尺度Logit模型的交通事故形态致因分析

为剖析典型交通事故形态致因,在利用最优尺度分析法诊断交通事故形态致因共线性的基础上,筛选关键影响因素,构建无序多分类Logit交通事故致因模型并对模型进行参数标定,并选择100个交通事故样本对模型进行精度验证,该模型相对误差仅为4.0％,能够较为准确地分析典型交通事故形态致因.研究结果表明:路侧及中央隔离设施、照明是事...     

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。