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。     

基于HFACS的化工企业火灾爆炸事故人因分析*

为研究化工企业火灾爆炸事故的主要人为因素,以63起火灾爆炸事故案例为样本,构建人为因素分析与分类系统（HFACS）模型,进行火灾爆炸事故人为因素分类统计与分析,并利用卡方检验和比值比分析HFACS模型上下层级间的因果关系。结果表明:HFACS模型中上下层级人为因素间存在显著的因果关系,层级1中的“不良的组织氛围”及“组织过程漏洞”和层级2中“监督不充分”在HFACS模型中可以显著增大事故发生的可能性,且“资源管理漏洞”、“不良的组织氛围”、“组织过程漏洞”→“监督不充分”→“人员因素”→“违规”是引发事故的关键路径,并根据HFACS模型中引发事故的关键路径及其人为因素的主要表现形式,提出针对性的化工企业火灾爆炸事故预防措施。     

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。     

A data-driven narratives skeleton pattern recognition from accident reports dataset for human-and-organizational-factors analysis

Accidents in the process industry involve several interacting factors, including human and organizational factors (HOFs). A long-standing obstacle to HOFs analysis is lack of data. Accident reports are an essential data source to learn from the past and contain HOFs-related data, but they are usually unstructured text in a not standardized format. Some studies have explored the extraction of information automatically from accident reports based on Natural Language Processing (NLP) techniques. However, they were not dedicated to HOFs. Risk communication is considered an essential pillar in safety and risk science. This research develops a HOFs-focused risk communication framework based on the NLP techniques that can support risk assessment and mitigation. The proposed approach automatically extracts the target groups oriented “Who, When, Where, Why” (4Ws) information from accident reports.This framework was applied to explore the eMARS database. The results show that the “4Ws” skeleton of narratives has appreciated performance in pattern recognition and holistic information analysis. The graphical representation interfaces are designed to display the features of HOFs-related accidents, which can better be communicated to the sharp-end operators and decision-makers.     

A study of maintenance-related major accident cases in the 21st century

This paper is based on a review of 183 detailed, major accident investigation and analysis reports related to the handling, processing and storage of hydrocarbons and hazardous chemicals over a decade from 2000 to 2011. The reports cover technical, human and organizational factors. In this paper, the Work and Accident Process (WAP) classification scheme is applied to the accident reports with the intention of investigating to what extent maintenance has been a cause of major accidents and what maintenance-related causes have been the most frequent.The main objectives are: (1) to present more current overall statistics of maintenance-related major accidents, (2) to investigate the trend of maintenance-related major accidents over time, and (3) to investigate which maintenance-related major accident causes are the most frequent, requiring the most attention in the drive for improvement.The paper presents statistical analysis and interpretation of maintenance-related major accidents’ moving averages as well as data related to the types of facility, hazardous substances, major accidents and causes. This is based on a thorough review of accident investigation reports.It is found that out of 183 major accidents in the US and Europe, maintenance was linked to 80 (44%) and that the accident trend is decreasing. The results also show that “lack of barrier maintenance” (50%), “deficient design, organization and resource management” (85%) and “deficient planning/scheduling/fault diagnosis” (69%) are the most frequent causes in terms of the active accident process, the latent accident process and the work process respectively.     

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。     

Origin of equipment design and operation errors

The paper discusses the origin of chemical process equipment accidents by analyzing past accident cases available in the Failure Knowledge Database (FKD). The design and operation errors of the process equipment that caused the accidents were analyzed together with their time of occurrence. It was found that design errors contributed to 79% of accidents while the rest were only due to human and organizational errors in the operation stage and external factors. The most common types of errors were related to layout, organizational errors in the operation stage, considerations of reactivity and incompatibility, and wrongly selected process conditions (each approx. 13% of total accident contributors). On average there were about 2 design errors per accident. The timing of the errors was quite evenly distributed between various lifecycle stages. Nearly half (47%) of the errors were made in process design-oriented stages, one fourth (26%) in detailed engineering, and one fifth (20%) in operation. In addition, the most frequent design and operation errors for each equipment type were identified. A points-to-look-for list was created for each equipment type, showing also the typical time of occurrence of the error. The knowledge of type and timing of design errors can be utilized in design to focus the hazard analysis in each stage on the most error-prone features of design.     

从事故特性谈人的安全意识的培养

缺乏安全意识是目前我国重特大伤亡事故发生的主要原因。事故的发生具有偶然性、必然性和可预防性等特性 ,充分认识事故的这些特性对提高安全意识水平有重要的意义。笔者对事故具有的一些基本特性及其与安全意识的关系进行了深入探讨 ,分析了安全意识的含义、特点及其表现形式 ,提出应结合事故的有关特性 ,通过文化、法制、经济等途径培养安全意识 ,不断提高社会公众的安全科技文化素质和自护技能水平。     

Safety in shipping: the human element

INTRODUCTION: There are numerous diverse papers that have addressed issues within maritime safety; to date there has been no comprehensive review of this literature to aggregate the causal factors within accidents in shipping and surmise current knowledge. METHODS: This paper reviewed the literature on safety in three key areas: common themes of accidents, the influence of human error, and interventions to make shipping safer. The review included 20 studies of seafaring across the following areas: fatigue, stress, health, situation awareness, teamwork, decision-making, communication, automation, and safety culture. RESULTS: The review identifies the relative contributions of individual and organizational factors in shipping accidents, and also presents the methodological issues with previous research. CONCLUSIONS: The paper concludes that monitoring and modifying the human factors issues presented in this paper could contribute to maritime safety performance. IMPACT ON INDUSTRY: This review illustrates which human factors issues are prevalent in incidents therefore this gives shipping practitioners a focus for interventions.     

医疗安全事故的组织因素研究

基于西安交通大学医学院第一附属医院发生的严重感染事件,简要介绍颇受关注的"组织事故"理论,尝试探索医疗事故的组织因素。做到医院安全行医,不仅要建立完善的医疗管理体系,并把管理制度深刻融入到组织成员的意识、观念中,加强安全医疗意识,还要加强医院感染应急系统及预案,建立可行的医疗风险防范机制及加强对医务工作者的管理;最重要的是在组织运营中不断发现和纠正其中的错误,提高组织的安全管理系统水平,体现安全文化的管理哲学。做到以上几点,才有可能避免医疗事故,让患者安全就医。     

An analysis of human factors in fifty controlled flight into terrain aviation accidents from 2007 to 2017

Introduction: Controlled Flight Into Terrain (CFIT) account for a considerable amount of fatalities when compared to other accident categories. Human factors are deemed significant contributory causes in these accidents. This paper aims to identify the human factors involved with aviation accidents that resulted in CFIT. Method: The study used the Human Factors Analysis and Classification System (HFACS) framework to determine the factors involved in 50 CFIT accidents from 24 counties over a 10 year period, i.e. 2007–2017. Interviews with five senior aviation safety experts were used to provide a better comprehension of the human factors affecting the flight safety. Results: The study identified 1289 individual causal and contributory human factors with unsafe actions and preconditions for unsafe actions being the main subcategories of the accidents. The study found that CFIT occur across a range of pilot experience and 44% of accidents occurred in cruise flight. Distraction, complacency and fatigue are all elements that flight crews may experience as contributors to CFIT during cruising. Conclusions: Human factors represent a major component of CFIT accidents. The analysis revealed a similar pattern of contributory and causal human factors across the various flight categories, with some noteworthy isolated variations. The prevalent factors were decision and skill-based errors along with communication, coordination and planning issues. Practical applications: Provision of specific CFIT awareness, pilot training focusing on improved decision-making and revision of basic flight skills, development of specific Global Positioning System routes for transiting high terrain areas are necessary to prevent CFIT accidents. Installation of Terrain Avoidance and Warning System and Ground Proximity Warning System and appropriate equipment training, specific CFIT Crew Resource Management training and improvement of organizational knowledge on the elements involved in CFIT are also recommended.     

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.     

基于哈默“人的差错理论”的道路交通安全研究

以道路交通安全系统为背景,人的差错为研究方向,运用"哈默"人的差错分类理论,从机动车驾驶员和非机动车驾驶员、乘客及行人两种人群的差错角度,对2004—2006年3年间我国交通事故发生率和死亡人数进行较有针对性的分析归类和研究,进而分别提出基于主动性和被动性两方面的交通事故人因预防措施。通过"哈默"全新的分类方法,全面分析交通行为中人的差错类型,为道路交通事故预防体系的研究、建立以及进一步的发展,提供了有参考价值的基于人的行为机理的理论依据和合理化建议。     

复杂社会技术系统事故成因结构敏感性分析

讨论基于共同成因假设思想的事故成因理论的局限:①不考虑系统复杂性影响,认为复杂系统和简单系统都遵循同样的事故成因机理;②共同成因假设,即大小事故具有相同的成因,遵循共同成因路径;③因果律假设,即任何事故一定有清晰严格的因果链;④只注重比较重要因素,人为增加了系统的不和谐。系统地阐述复杂系统事故所具有的结构敏感性,给出了事故成因模型有效性的价值判断标准,并提出活跃元素的行为偏差及活跃元素间交互作用偏差的合成是决定复杂社会技术系统事故成因机理的学说,补充并完善了Reason的Swisscheese模型,同时构建了基于结构敏感性的事故成因模型。     

Process Safety Management (PSM) for managing contractors in process plant

Accidents involving contractors continue to occur with regular frequency. By using the standard set within the PSM 29 CFR 1910.119(h) regulations, it has been identified that certain aspects of the way contractors do work are not up to the stipulated regulatory requirements especially regarding matters like not providing mandatory personal protective equipment (PPE) to the workers, not discussing hazards related to handling procedures with the workforce and improper control of non-routine activities during changes in shifts. The PSM 29 CFR 1910.119(h) regulations promulgated in 1992 provides standards that covered processes to obtain and evaluate data regarding contractors' health and safety programs as well as the contractors' performance evaluation. Many of the accidents involving contractors are direct result of poor training of contractors and/or poor control of the contracted work. Even though most organizations have their own contractor management systems, there are issues in meeting the requirements of PSM. The PSM standard only state “what to do” not “how to do it”. This is known as self-regulatory policy which depends on the industries understanding to interpret the standard that also contribute to this problem. This paper presents a structured and easy technique to plan and implement a practical and comprehensive contractors' management system in process industries that will comply with OSHA CFR 1910.119. A model has been developed based on this technique and its application has been tested in a pilot plant for compliance to PSM regulation. The model is beneficial to the process industries as any deficiencies in the PSM contractors' management program will be highlighted by the model which will then easily correct the identified deficiency so as to minimize and prevent catastrophic accidents.     

Multilevel learning from accidents – Case studies in transport

Substantial efforts have been devoted to accident investigations, but do we gain a reasonable benefit from these efforts? The current study explores multilevel (individual, company, sector/trade, authorities) learning from major accidents and serious incidents. Specifically, this involves identifying a set of learning criteria, i.e. factors or indicators that potentially support and contribute to multilevel learning processes. Identifying such criteria is based on: (i) the accident investigation process, (ii) the follow-up efforts, and (iii) contextual aspects. Three Norwegian accident investigations in transportation (aviation, marine, rail) represent the empirical foundation for the study. Learning criteria were derived by both document analyses from the accidents (e.g. investigation reports) and literature reviews on organizational learning. These were the basis for a workshop regarding learning from accidents, with participants from the aviation, marine, and rail sector. Key results from this workshop are presented and discussed. The study concludes by presenting a set of criteria for learning from accidents.     

基于数据挖掘的化工生产事故致因主题抽取

为充分挖掘化工生产事故数据中的有效信息和潜在规律,提高对化工事故认知水平,针对某化工集团2010—2016年共1 578起事故数据,利用社会网络分析等方法揭示事故要素间的关联关系;运用潜在狄利克雷分配（LDA）模型进行事故聚类,并抽取到5个事故致因主题。研究结果表明:LDA主题模型等数据挖掘技术能有效挖掘大量事故数据中的潜在信息;5个事故致因主题中,4个涉及到人因或组织层面的缺陷;员工注意力不集中和现场风险管理不足这2个致因主题间具有较强相关性;员工注意力不集中、现场风险管理不足以及设备问题是导致事故发生的主要原因。     

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。     

2004—2008年我国隧道施工事故统计分析

为了解我国隧道施工事故的发生规律,采用柱状图和事故发生趋势图等方法对2004—2008年隧道施工事故进行统计与分析,获得了事故次数与死亡人数的年度分布和发展趋势、不同事故类型发生事故次数、事故类型占总事故数百分比、地区分布、事故等级分布等统计特征。找出2004—2008年隧道施工事故的发生规律:事故次数和死亡人数均呈下降趋势;事故类型以坍塌、物体打击、透水、冒顶片帮为主,其中坍塌是隧道施工过程中的第一要害;事故主要集中在中西部地区,东部地区则很少;多数事故为较大事故,发生重大和特别重大事故较少,但多为恶性事故。同时根据隧道施工事故发生规律,提出隧道施工安全管理的对策与建议。     

Accidents in the chemical industry: are they foreseeable?

‘Accidents recur,’ which is what Kletz [Kletz T. (1993). Lessons from disasters, how organisations have no memory and accidents recur. UK: Institution of Chemical Engineers] wrote in 1993. Indeed, despite all measures taken accidents may re-occur, but ‘disruptions’ in a process reoccur much more frequently. If a disruption occurs it may lead to an accident. If the same disruption reoccurs it is certainly suspect and should be considered as a potential precursor. In this paper, we concentrate on these disruptions and we will define them as precursors if they recur. Organizations somehow lack the ability to control such recurring disruptions that may escalate into serious accidents under certain circumstances. The presence of such precursors long before the occurrence of an accident raises doubts about how well organizations control safety.In this paper, the control mechanism inside organizations is examined, by means of several accident investigations. It will be shown that not only accidents recur, but also that disruptions recur in a period preceding the actual accident. The recurrence of these disruptions implies that the corresponding organizational control mechanism must be failing. Often, alternative circumstances prompt the escalation of such precursors and lead to actual accidents. It is demonstrated that the use of detailed accident information is of great importance for companies that are actually willing to prevent accidents through the elimination of disruptions preceding accidents.