人为差错成因分析方法研究

控制甚至消除人为差错成因能从本质上降低人为差错的发生概率,从而提高系统安全性。因此,辨识和分析人为差错成因是一件非常必要而又十分重要的工作。针对该问题,在总结和分析现有的人为差错成因分析方法的基础上,提出了一种新的人为差错成因分析框架。在该框架中,将差错成因分为"操作者-系统-任务-环境-组织因素"5个方面进行分析,并提出了"从大类到小类"的层次化分析原则。为了尽量降低不同差错成因之间的关联,提出了以任务为中心,将差错成因分为任务相关和任务无关两大类因子的分类方式。最终共分析得出了34种不同的差错成因。该差错成因分类框架的提出,为人为差错概率量化以及差错规避措施的设计提供了依据。

Study on Causation Analysis Method for Human Errors

Control and Elimination of the causes to human errors is quite helpful to reduce the likelihood of the human errors and improve the system safety from the root.Therefore,it is necessary to identify and analyze the human errors causes.To solve this problem,a new framework for human error causes analysis is presented based on overview of the existing framework.In this framework,these causes are analyzed from the aspects of Operator,System,Task,Environment and Organization.The principle of hierarchical analysis of causes is presented.And in order to reduce to dependency levels among different causes,the errors causes are analyzed centered by the aspect of Task,so the causes are divided into two subtypes,which are task-related and task-unrelated causes.Finally,Thirty-four causes are identified totally.They are the base to human error probability quantification and error countermeasures design.