复杂人——机系统中的人因失误

随着人——机系统变得越来越多，装置的可靠性越来越高，人因失误已成为重要的潜在事故源。本文描述了复杂人——机系统的特征，探讨了该系统中人因失误的定义、分类、数据采集和事故模型。这些研究有助于对人因失误的预测、预防和减少。     

预防事故的重要途径——人为失误控制

从伤亡事故致因理论和我国大多数企业的安全管理现状出发，分析说明人为失误控制是预防事故的重要途径，并具体介绍了人为失误控制的两种主要技术方法。     

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.     

论人的失误

人的失误所造成的事故占事故总数的７０—８０％，研究人的失误对控制伤亡事故的发生具有重要意义。为此，分析人的行为模式，论述人失误的原因，并对控制人失误的方法进行了探讨，认为减少人失误的根本途径是大力倡导安全文化，提高操作者的安全素质。     

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。     

Systems-based accident analysis methods: A comparison of Accimap, HFACS, and STAMP

Three accident causation models, each with their own associated approach to accident analysis, currently dominate the human factors literature. Although the models are in general agreement that accidents represent a complex, systems phenomenon, the subsequent analysis methods prescribed are very different. This paper presents a case study-based comparison of the three methods: Accimap, HFACS and STAMP. Each was used independently by separate analysts to analyse the recent Mangatepopo gorge tragedy in which six students and their teacher drowned while participating in a led gorge walking activity. The outputs were then compared and contrasted, revealing significant differences across the three methods. These differences are discussed in detail, and the implications for accident analysis are articulated. In conclusion, a modified version of the Accimap method, incorporating domain specific taxonomies of failure modes, is recommended for future accident analysis efforts.     

Trends in chemical hazards in Japan

In the past, the chemical industry in Japan has been the cause of a number of major industrial accidents. Subsequent to each accident, specific lessons have been learned. These lessons learned have been implemented in terms of safety education of the employees and/or safety measures of the equipment and facilities resulting in a rapid decrease of corresponding accident frequencies. In this paper, we summarized both recent and past major accidents caused by chemical substances in fixed installations in Japan. Case studies show that runaway reactions are among the main causes of major accident occurrences in the chemical process industry in Japan. A recent fatal poisoning accident caused by H₂S gas generated during maintenance work again highlights the necessity of adequate safety management in a chemical factory. Therefore, even if hazard evaluation of chemical substances and chemical processes is necessary to prevent runaway reactions, human error is also an important factor contributing to reaction hazards [Wakakura, M. (1997) Human factor in chemical accidents, J. Safety Eng. High Press. Gas. Safety Inst. Japan, 34, 846].     

航空维修人为差错影响因素分析中的模糊层次分析法

航空维修中的人为差错影响因素分析对于预防事故发生至关重要,如何定量分析及辨识出主要影响因素是亟待解决的问题。为此,结合航空维修实际,提出运用群组模糊层次分析法对人为差错影响因素进行量化排序和分类,归纳细化了影响因素层次体系,并给出了分析计算流程。以一起由维修人为差错所引发的航空事故为例进行了实证分析,结果表明:该方法能够辨识出航空维修中人为差错产生的主要影响因素,进而对制订最优事故预防方案,控制和减少该类事故的发生有积极意义。同时该方法对其他行业中的人为差错主要影响因素辨识有着一定的参考价值。     

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。     

Why did the pilots shut down the wrong engine? Explaining errors in context using Schema Theory and the Perceptual Cycle Model

Although human error remains a dominant issue in aviation research, methods that predict human error have been criticised for not providing adequate causal explanations, rather they have focused on classification. The concept of Schemata has prevailed in the literature and has been shown to describe the contextual causes of human error. The purpose of this paper is to review the recent error literature and demonstrate that Schema Theory (as incorporated in the Perceptual Cycle framework) offers a compelling causal account of human error. Schema Theory offers a system perspective with a focus on human activity in context to explain why apparently erroneous actions occurred, even though they may have appeared to be appropriate at the time. This is exemplified in a case study of the pilots’ actions preceding the 1989 Kegworth accident. Schema Theory is presented as a promising avenue for further exploration into the context of human error in aviation.     

Overcoming the blame game to learn from major accidents: A systemic analysis of an Anhydrous Ammonia leakage accident

This article aims to demonstrate the need for changing the methods with which accidents are analyzed, if we truly wish to use what we uncover from them to learn and enrich our knowledge base of organizational management. The goal is to relinquish the broadly adopted and rather simplistic paradigm that accepts the search for human error and unsafe acts performed by workers, and produces “guilt diagnostics”. Instead, we use a systemic accident analysis methodology, based on the sociotechnical principle of understanding the real operating conditions in which accidents take place. In order to demonstrate the benefits of the theoretical framework, we compare the analyses of an Anhydrous Ammonia gas leakage accident in a fish processing plant using the traditional accident analysis model based on unsafe acts and the proposed systemic approach. The results favor the latter since it tends to be more reliable and offering useful recommendations to safety management processes, thus helping to prevent accidents, especially in complex systems.     

Learning from accidents – What more do we need to know?

A model of experience feedback (the CHAIN model) that emphasizes the whole chain from initial reporting to preventive measures is used to identify important research needs in the field of learning from accidents. Based on the model, six quality criteria for experience feedback after an accident or incident are presented. Research on experience feedback from accidents is reviewed. The overall conclusion is that the discipline of experience feedback has not been sufficiently self-reflective. The process of experience feedback can and should be applied to experience feedback itself, but that is rarely done. Evaluation studies are needed that provide hard (evidence-based) information about the effects of various methodologies and organizational structures. Four types of studies are particularly important for the development of evidence-based accident investigation practices: (1) studies of the effects and the efficiency of different accident investigation methods, (2) studies of the dissemination of conclusions from accident investigation, (3) follow-up studies of the extent to which accident investigation reports give rise to actual preventive measures, and (4) studies of the integration of experience feedback systems into overall systems of risk management.     

人为失误及其辨识技术的研究

随着机器设备的可靠性不断提高，人的可靠性分析研究日益得到重视。大部分事故是由于人为失误造成的。分析了人为失误与事故发生的关系，讨论了管理失误对系统安全的影响；讨论了人为失误辨识的作用，对人为失误率预测技术、通过失误建模系统、人为失误率评价和优化系统等几种的人为失误辨识技术进行了评述。指出了人为失误及其辨识技术的发展趋势和方向。     

一种基于认知过程分析的人因失误辨识方法——应用于高速铁路列车调度系统

通过总结既有的人因失误分类方法,对主要分类方法的优缺点和适用性进行了评述。既有的人因失误分类方法主要侧重于人因事故分析,在对人的认知过程四阶段尤其是计划决策阶段的失误模式进行主动辨识具有较大的困难。通过综合认知行为四阶段模型和技能型-规则型-知识型行为理论(SRK理论),建立了高铁列车调度指挥认知行为SRK模型。以认知行为SRK模型为基础,提出一种新的人因失误分类方法用以人因失误辨识。以高铁列车调度指挥临时限速为任务背景,进行实际的人因失误辨识工作,并给出了详细的辨识结果。通过对列车调度员的访谈,辨识结果全面覆盖了临时限速时可能出现的人因失误类型,验证了方法的实用性。     

库存弹药事故人误危险性分析与评估模型研究

针对库存弹药安全的特殊性,提出库存弹药事故人为失误的定义,并从个体角度分析人误事件发生的机理。根据人为失误的不同主体,从管理决策、组织和勤务处理、操作两个方面构建了29个人误危险性的评价指标及相应的评判标准;综合考虑生理、心理、知识与技能、设备、环境、监督与管理等6类危险性抵消因子对人误危险性的影响;进而建立了库存弹药事故人误危险性的理论评估模型。研究结果表明:人为失误属于弹药仓储安全管理中的一类特殊危险源,人误评估指标体系和评估模型的构建过程应充分考虑人自身条件以及内、外部环境等因素的综合影响;同时研讨了人为失误危险性分析和评估模型存在的问题,并从发展人误数据采集技术、完善人误事故报告制度以及建立人误数据库等方面,指出下一步的研究重点。     

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.     

An application of data mining tools for the study of shipping safety in restricted waters

The effectiveness of the enforcement of the ISM-Code and the examination of its role in the distribution of causes of shipping accidents between human and non-human error was studied. All accidents involving Greek-flagged ships from 1995 to 2006, a time-scale which spans over the pre- and post-ISM period in navigational regions of restricted waters, were analyzed.The accident data was processed through a classification tree analysis which enabled the classification of various accident factors. The analysis revealed that although the human error maintained its position as the dominant factor in shipping accidents, there is also substantial evidence in support of the ISM-Code effective control over shipping accidents during the post-ISM period. The implementation of the ISM-Code led to an overall reduction of human-induced accidents in total. Furthermore, in terms of location, the ISM-Code improved the human-induced accident record within restricted waters.Conclusively, the ISM-Code constitutes an effective policy measure for shipping safety. The results of the classification tree analysis reported in the present work can be used by decision makers in companies and international organizations to build knowledge-based expert systems and augment their information in the field of safety policy and management.     

Allocation of performance shaping factors in the risk assessment of an offshore installation

Offshore oil production is one of the most important human productive activities. There are many risks associated with the process of constructing a subsea well, pumping oil to the platform, and transporting it to refineries via underwater pipes or oil tankers. All actions performed by workers in those operations are influenced by specific working conditions, involving the use of complex systems. Contextual factors such as high noise, low and high temperatures and hazardous chemicals are considered to be contributors to unsafe human actions in accident analysis and also give a basis for assessing human factors in safety analysis. Some failure modes are particularly dangerous and can result in severe accidents and damage to humans, the environment and material assets. Fires and explosions on oil rigs are some of the most devastating types of offshore accidents and can result in long-term consequences. The most typical root causes related to accidents include equipment failure, human error, environmental factors, work organization, training and, communication, among others. The principal objective of this study is to propose a methodological framework to identify the factors that affect the performance of operators of an offshore unit for oil processing and treatment. In this phase, an ergonomics approach based on operators' work analysis is used as a supporting tool. After identification of factors that affect the performance of operators, a decision-making model based on AHP (analytic hierarchy process) is applied to rank and weight the principal performance shaping factors (PSFs) that influence safe operations. The next step involves the use of the SHELLO model to group the main PSFs in elements named software, hardware, environment, liveware and organization. In the last phase, a relevant accident that occurred aboard a floating production storage and offloading (FPSO) vessel is analyzed. The allocation process of the factors that affect the operator's performance in risk assessment was developed through fuzzy logic and the ISO 17776 standard.     

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.