组织定向的人因失误因果模型及影响关系研究

为了更好地从源头上预防人因失误,首先,基于系统理论发展一个组织定向人因失误的"结构-行为"因果模型,包括组织子模型、情境状态子模型、个体因素子模型以及人因失误子模型。然后,分析模型中各子模型之间以及其因素类别之间的直接和间接影响关系,如模型中各层级之间的因果关系:组织因素→情境状态因素→直接触发人因失误的个体因素→人的认知行为失误。最后,基于事件报告分析、专家意见和文献资料,并依据建立的4种影响类型(I,C,A,N)识别具体情境环境与人因失误或认知行为之间的影响关系。分析结果表明,情境环境因素对人因失误的影响非常复杂,不同的情境环境因素对同一人因失误可能产生不同类型的影响,同一情境环境因素对不同的人因失误可能产生不同类型的影响。

Study on Organization-oriented Causation Models of Human Error and Their Influencing Relationship

Firstly,based on system theory,this paper develops an organization-oriented "structural and behavioral" causal model of human error in order to better prevent human error,which includes organizational sub-model,situational sub-model,individual factors sub-model and human error sub-model. Secondly,the direct and indirect influencing relationship among these sub-models and the relationship among different types of factors in each sub-model are analyzed. For example,the causal relationship (organizational factors→situational factors→individual factors triggering human error→human error) between the various levels in the model are identified. Finally,the influencing relationships between the concrete context and human errors or human cognitive activities are identified on the basis of human factor event/accident analysis,experts' opinion,literature findings and the establishment of four types of influencing (I,C,A,N). The results show that the effects of the context on human error are very complex. Different context may produce different types of influence on the same human error,and the same context may also produce different types of influence on different human errors.