核电厂操纵员人因失误影响因素分析

为研究核电厂操纵员的行为影响因素(PIFs)以及它们间的关联关系,通过文献分析,从组织视角建立比较全面具体的PIFs分类体系。统计分析核电厂大量人因事件,识别影响操纵员人因失误的重要因素。基于人因事件样本数据,对PIFs进行相关性分析,研究PIFs之间的相互影响关系。研究表明:影响核电厂操纵员的主要因素为个体因素中的心理状态、素质和能力,情境环境因素中的规程、培训和组织管理等因素;个体因素受各种情境环境因素的影响,但不同的个体因素与各种情境环境因素的影响关系不同,如心理状态主要受人的素质和能力、技术系统等影响,而人的生理状态主要受工作环境、班组因素和组织结构等影响。     

核电厂HRA组织定向研究

概率安全评价(PSA)已经成为核电厂定量化安全评价的主要方法,人因可靠性分析(HRA)是其中重要组成部分.传统的HRA方法研究对象主要是"个体失误",而HRA的全面评估必须考虑"组织情景",HRA必须组织定向.分析了HRA各主要方法对于组织因素考虑的不足,提出了HRA组织定向的必要性和基本原则.在提出组织定向的假设条件基础上,建立了HRA(A、B、C类事故)与核电厂相关特定组织之间的映射模型.     

国家安全生产监督管理总局公告

[2012年第28号]依据《安全生产检测检验机构管理规定》(国家安全监管总局令第12号)和《安全生产检测检验机构资质认定评审通用准则》(安监总规划〔2007〕28号)、《安全生产检测检验机构能力的通用要求》(AQ8006-2010)等有关规定,根据有关省级安全监管局、煤矿安监局审查推荐意见,经组织有关单位和专家评审,决定批准符合相应资质条件的湖南省烟花炮竹产品安全质量监督检验醴陵授权站等3家安全生产检测检验甲级机构     

如何做好职业安全健康初始评审

1 概述 对于一个组织,职业安全健康管理工作是一项重要的管理内容,存在于原料运输、贮存、输送、产品的生产以及设备的维护检修等过程。对于初次按标准要求建立体系的组织,对其现状需要进行一次初始状态评审,作为体系建立的条件和基础,这是建立职业安全健康管理体系不可缺少的一项策划活动。 职业安全健康初始评审,是明确组织职业安全健康现状的必要手段,也是对组织的职业安全健康管理活动进行初始综合分析和评价。通过初始状态评审,达到以下几个目的:(1)识别和获取适用于组织的职业安全健康法规及其它要求;(2)识别出组织的危险源并进行危险源风险评价及风险     

第四讲 OHSMS标准的运行模式、特征及功能

4 1　ＯＨＳＭＳ标准的运行模式ＯＨＳＭＳ标准的思想建立在戴明ＰＤＣＡ管理理论基础上的 ,其运行程式按如下过程进行 :方针、目标、计划 (Ｐ)→职责、运行、实施 (Ｄ)→监测、检查、审核 (Ｃ)→评审、纠正、改进 (Ａ) ,这一运行模式可见图 4 - 1。戴明管理理论和模式将在下面的基础管理理论中介绍。从图 4 - 1可看出 :ＯＨＳＭＳ的基本思想是实现体系持续改进 ,通过周而复始的进行“计划、实施、监测、评审”活动 ,使体系功能不断加强。它要求组织在实施ＯＨＳＭＳ时始终保持持续改进意识 ,结合自身管理状况对体系进行不断修正和完善 ,最…     

基于HFACS的电梯人因风险因素监管方法研究

为了分析电梯事故发生的原因,以国家特种设备安全监察局通报数据为样本,基于人因分类与分析系统(HFACS)和层次分析法(AHP)开展电梯事故人因分析,构建改进型电梯设备人因风险监管体系,辨识出电梯设备使用与管理过程中4大人因风险类别及20项人因风险因素,并对风险监管内容进行细化;运用层次分析法求解20项人因风险因素权重,确定相应风险等级,并阐明各人因风险因素在使用与管理环节中的安全监管内容。结果表明:安全装置缺陷及日常的维护保养中人因风险等级最高,需重点监控,最后通过建立"三位一体"安全监管模式,以保障电梯使用和管理运行安全。     

核电厂人因事故预防的定量化决策

人因事故的分析与预防是核电厂安全运行和管理的重要内容。笔者提出的系统安全性层次分析法主要从两种角度考虑系统的安全性:专家能力权值和安全性矩阵的建立。采用专家判断矩阵确定事故原因对系统安全性的重要度排序。举例某核电厂事故定量分析进行说明,在对事故进行原因分析基础上,构建事故影响因素层次模型,利用层次分析法分析得出事故原因重要度排序由高到低依次为组织管理、操作人员、人机界面、培训与设备状态,并据此提出了相应的预防与改进措施,为安全性要求较高的复杂工业系统提供事故预防的定量化决策依据。     

职业安全卫生管理体系(OHSMS)(续) 第四讲 OHSMS标准的运行模式、特征及功能

4.1　 OHSMS标准的运行模式OHSMS标准的思想是建立在戴明 PDCA管理理论基础上的 ,其运行程式按如下过程进行 :方针、目标、计划 (P)→职责、运行、实施 (D)→监测、检查、审核 (C)→评审、纠正、改进 (A) ,这一运行模式可见图 4 1。戴明管理理论和模式将在下面的基础管理理论中介绍。图 4 1　OHSMS的运行思想从图 4 1可看出 :OHSMS的基本思想是实现体系持续改进 ,通过周而复始的进行“计划、实施、监测、评审”活动 ,使体系功能不断加强。它要求组织在实施 OHSMS时始终保持持续改进的意识 ,结合自身管理状况对体系进行不断修…     

基于ISM和AHP法的矿工习惯性违章行为影响因素研究

为深入研究矿工习惯性违章行为的影响因素及其作用模式,从个体、管理、组织、工作本身等层面建立矿工习惯性违章行为影响因素指标体系。采用解释结构模型(ISM)分析各因素之间的联系,建立3级多层递阶ISM。应用层次分析法(AHP)对结构模型中各因素指标的影响力排序,建立指标综合权重体系。结果表明:表层直接影响因素集中于个体因素和组织因素。中层间接影响因素主要涉及个人传记特征和工作本身因素。深层根本影响因素全部集中于管理因素。安全生产投入、安全教育培训、个体心理状况、个体安全意识、安全管理制度是习惯性违章行为的主要影响因素。建议以加大安全投入力度、增强安全培训多样性、强化管理者的行为等措施,预防和控制习惯性违章行为。     

核电厂运行阶段安全文化评价指标体系研究

为培育良好的核电厂运行阶段安全文化,通过分析核电厂运行特征,总结已有的核安全文化评价指标体系和评价模型,构建核电厂运行阶段安全文化评价指标体系,划分为价值观、行为、系统和环境4个层次,并细分出13个二级指标和61个三级指标;在此基础上,考虑到指标之间的非独立性和可能存在的相互影响关系,提出一种基于决策试验和评价实验法(DEMATEL)以及网络层次分析法(ANP)相结合的综合方法,确定指标体系的权重。结果表明：该方法结合调研数据,可得到核安全文化评价指标权重,并甄别出改善核安全文化的关键在于决策层的安全意识、以身作则等指标,为核电厂运行阶段安全文化的培育提供指导。     

Determinants of safety outcomes and performance: A systematic literature review of research in four high-risk industries

IntroductionIn spite of increasing governmental and organizational efforts, organizations still struggle to improve the safety of their employees as evidenced by the yearly 2.3 million work-related deaths worldwide. Occupational safety research is scattered and inaccessible, especially for practitioners. Through systematically reviewing the safety literature, this study aims to provide a comprehensive overview of behavioral and circumstantial factors that endanger or support employee safety.MethodA broad search on occupational safety literature using four online bibliographical databases yielded 27.527 articles. Through a systematic reviewing process 176 online articles were identified that met the inclusion criteria (e.g., original peer-reviewed research; conducted in selected high-risk industries; published between 1980-2016). Variables and the nature of their interrelationships (i.e., positive, negative, or nonsignificant) were extracted, and then grouped and classified through a process of bottom-up coding.ResultsThe results indicate that safety outcomes and performance prevail as dependent research areas, dependent on variables related to management & colleagues, work(place) characteristics & circumstances, employee demographics, climate & culture, and external factors. Consensus was found for five variables related to safety outcomes and seven variables related to performance, while there is debate about 31 other relationships. Last, 21 variables related to safety outcomes and performance appear understudied.ConclusionsThe majority of safety research has focused on addressing negative safety outcomes and performance through variables related to others within the organization, the work(place) itself, employee demographics, and—to a lesser extent—climate & culture and external factors.Practical applicationsThis systematic literature review provides both scientists and safety practitioners an overview of the (under)studied behavioral and circumstantial factors related to occupational safety behavior. Scientists could use this overview to study gaps, and validate or falsify relationships. Safety practitioners could use the insights to evaluate organizational safety policies, and to further development of safety interventions.     

An adaptive management system for hazardous technology organizations

This paper introduces a management system suitable for hazardous technology organizations which has been developed based on the assumptions that in these organizations safety is a critical strategic factor, the existence of an enhanced safety culture is a crucial condition for safety and that safety culture enhancement implies in organizational changes. The management system was theoretically developed and then implemented at a Brazilian nuclear research and development installation, as a case study, in order to validate the theoretical propositions assumed in the system development. The developed management system comprises a day-to-day based organizational framework which treats safety as one of the organization strategic perspectives and provides a continuous adaptation of the complex causal inter-relationships which occur between the implementation of new management practices – designed and implemented according to the requirements of the criteria of excellence of the Brazilian quality award management assessment model – and the organization safety culture. The results achieved in the case study permitted to demonstrate the validness of all the system theoretical propositions and to conclude that the continuous and systematic operation of the management system makes an effective safety culture enhancement possible and simultaneously facilitates that the new management practices be effectively implemented, thus making continuous organizational improvement possible.     

Human and organisational factors in the operational phase of safety instrumented systems: A new approach

The international standards IEC 61508 and IEC 61511, which provide a general framework for the design and implementation of safety instrumented systems, require quantification of the achieved risk reduction, expressed as a safety integrity level (SIL). Human and organisational factors affect the performance of safety instrumented systems during operation and may threaten the achieved SIL, but this is usually not explicitly accounted for. This article presents a new approach to address human and organisational factors in the operational phase of safety instrumented systems. This approach gives a prediction of the operational SIL and can also be used to improve safety. It shows which human and organisational factors are most in need of improvement and it provides guidance for preventive or corrective action. Finally, the approach can be used as part of a SIL monitoring strategy in order to maintain the achieved SIL at the required level during the operational phase.     

Introducing the STAMP method in road tunnel safety assessment

After the tremendous accidents in European road tunnels over the past decade, many risk assessment methods have been proposed worldwide, most of them based on Quantitative Risk Assessment (QRA). Although QRAs are helpful to address physical aspects and facilities of tunnels, current approaches in the road tunnel field have limitations to model organizational aspects, software behavior and the adaptation of the tunnel system over time. This paper reviews the aforementioned limitations and highlights the need to enhance the safety assessment process of these critical infrastructures with a complementary approach that links the organizational factors to the operational and technical issues, analyze software behavior and models the dynamics of the tunnel system. To achieve this objective, this paper examines the scope for introducing a safety assessment method which is based on the systems thinking paradigm and draws upon the STAMP model. The method proposed is demonstrated through a case study of a tunnel ventilation system and the results show that it has the potential to identify scenarios that encompass both the technical system and the organizational structure. However, since the method does not provide quantitative estimations of risk, it is recommended to be used as a complementary approach to the traditional risk assessments rather than as an alternative.     

基于模糊层次分析法的组织因素影响度识别

基于模糊层次分析理论,构建影响系统安全的组织因素模型,确定影响系统安全的组织因素指标体系,利用因素相对影响度R、因素总体影响度C和因素重要度I来表征组织因素对系统安全的影响程度。采用该因素影响度方法分析了组织因素对某核电站系统安全的影响,发现监督、安全文化培训、领导对安全的态度、程序的完备性、部门间的交流与反馈、协调、个人的意识和态度、岗前技能培训、部门内的交流与反馈是对核电站运行安全影响最大的组织因素。     

Diagnosis of safety culture in safety management audits

Based on the sociotechnical systems approach, an understanding of safety culture as deeply rooted assumptions about the interplay of people, technology, and organization in their relation to safety is presented. As a complement to audit methods aimed at assessing formal safety management, a questionnaire was developed which allows some indications of these assumptions to be captured by providing data on perceptions regarding operational safety, safety and design strategies, and personal job needs. Analyzing response patterns of different occupational, hierarchical, and organizational groups within a company in combination with formal audit results and the communicative validation of both in a feedback meeting can help the auditors as well as the members of the company to gain a deeper understanding of safety management and safety culture in that company. Results from seven audits in petrochemical plants are presented and discussed with respect to the validity and practicability of the chosen approach.     

Incorporating organizational factors into probabilistic risk assessment of complex socio-technical systems: Principles and theoretical foundations

The current generation of Probabilistic Risk Analysis (PRA), particularly those for technical systems, does not include an explicit representation of the possible impacts of organization and management on the safety performance of equipment and personnel. There are a number of technical challenges in developing a predictive model of organizational safety performance. There is a need for a widely accepted and theoretically sound set of principles on which models of organizational influences could be developed and validated. As a result of a multidisciplinary effort, this paper explores the feasibility of developing such principles and proposes a set of principles for organizational safety risk analysis. Then, as a realization of the proposed modeling principles, a safety risk framework, named Socio-Technical Risk Analysis (SoTeRiA), is developed. SoTeRiA formally integrates the technical system risk models with the social (safety culture and safety climate) and structural (safety practices) aspects of safety prediction models, and provides a theoretical basis for the integration. A systematic view of safety culture and safety climate leaves an important gap in modeling complex system safety risk, and SoTeRiA, describing the relationship between these two concepts, bridges this gap. The framework explicitly recognizes the relationship among constructs at multiple levels of analysis, and extends the PRA framework to include the effects of organizational factors in a more comprehensive and defensible way.     

Leading indicators of system safety – Monitoring and driving the organizational safety potential

An indicator can be considered any measure – quantitative or qualitative – that seeks to produce information on an issue of interest. Safety indicators can play a key role in providing information on organizational performance, motivating people to work on safety and increasing organizational potential for safety. We will describe the challenges of monitoring and driving system safety. Currently, the same lead indicators are used – explicitly or implicitly – for both purposes. The fact that the selection and use of safety performance indicators is always based on a certain understanding (a model) of the sociotechnical system and safety is often forgotten. We present a theoretical framework for utilizing safety performance indicators in safety–critical organizations that incorporates three types of safety performance indicators – outcome, monitor and drive indicators. We provide examples of each type of indicator and discuss the application of the framework in organizational safety management. We argue that outcome indicators are lag indicators since outcomes always follow something; they are the consequences arising from multiple other situational and contextual factors. Monitor and drive indicators are lead indicators. The main function of the drive indicators is to direct the sociotechnical activity in the organization by motivating certain safety-related activities. Monitor indicators provide a view on the dynamics of the organization: the practices, abilities, skills and motivation of the personnel – the organizational potential for safety. We conclude that organizations should better acknowledge the significance of monitor and drive indicators in safety management.     

The art of measuring nothing: The paradox of measuring safety in a changing civil aviation industry using traditional safety metrics

Measuring safety as an outcome variable within the ultra-safe civil aviation industry during periods of deliberate organizational change is a difficult, and often fruitless, task. Anticipating eroding safety processes, based on measuring nothing happening over time, does not adequately capture the true state of an evolving safe system, and this is particularly relevant for leaders and managers in a civil aviation industry responsible for maintaining and improving ultra-safe performance while simultaneously managing demanding strategic business goals.In this paper, I will look at the difficulties of measuring safety as an outcome measure in high reliability organizations (HROs) using the traditional measures of incident and accident reporting during periods of deliberate organizational change inspired by the results from a 3 year longitudinal case study of the Norwegian Air Navigation Services provider – Avinor. I will first review the current safety literature relating to safety management systems (SMSs) used in the civil aviation industry. I will then propose a more holistic model that shifts the focus from the traditional safety monitoring mechanisms of risk analysis and trial and error learning, to the natural interactivity within socio-technical systems as found in high reliability organizations. And finally, I will present a summary of the empirical results of an alternate methodology for measuring perceived changes in safety at the operational level as leading indicators of evolving safety at the organizational level.     

Embedding the human factor in road tunnel risk analysis

The paper is focusing on road tunnel safety and builds upon the Directive 2004/54/EC launched by the European Commission; the latter sets basic requirements and suggests the implementation of risk assessment in several tunnel cases apart from technical measures imposed on the basis of tunnel structural and operational characteristics. Since the EU Directive does not indicate the method for performing risk assessment, a wide range of methods have been proposed, most of them based on quantitative risk assessment (QRA). Although the majority of current road tunnel QRAs assess physical aspects of the tunnel system and consider several hazards concerning the transportation of dangerous goods through a tunnel, they do not take into account, sufficiently, several organizational and human-related factors that can greatly affect the overall safety level of these critical infrastructures. To cope with this limitation this paper proposes a fuzzy logic system based on CREAM method for human reliability analysis (Hollnagel, 1998) in order to provide more sophisticated estimations of the tunnel operator's performance in safety critical situations. It is deduced that a human reliability analysis component to analyze operator performance, like the fuzzy system proposed here, is important for risk analysts. Consideration of organizational and human factors will enhance risk analysts’ studies and highlight the uncertainty related to human performance variability.