Determination of human error probabilities for offshore platform musters

The focus of this work is on prediction of human error probabilities during the process of emergency musters on offshore oil and gas production platforms. Due to a lack of human error databases, and in particular human error data for offshore platform musters, an expert judgment technique, the Success Likelihood Index Methodology (SLIM), was adopted as a vehicle to predict human error probabilities. Three muster scenarios of varying severity (man overboard, gas release, and fire and explosion) were studied in detail. A panel of 24 judges active in the offshore oil and gas industry provided data for both the weighting and rating of six performance shaping factors. These data were subsequently processed by means of SLIM to calculate the probability of success for 18 muster actions ranging from point of muster initiator to the final actions in the temporary safe refuge (TSR). The six performance shaping factors considered in this work were stress, complexity, training, experience, event factors and atmospheric factors.     

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 The tool is easy-to-use in occupational environments, and includes assessments of human behavior and potentially outdated machinery at work place.     

人失误模型在防止变电所检修事故中的应用

针对变电所检修事故的特点,认为人失误是导致该类事故发生的主要原因。运用安全人机工程学基本原理,分析了变电所检修过程中人失误产生的原因,在研究了以人失误为主因的事故模型基础上,进一步从人的特性、人机功能的分配、人机界面的设计、安全管理和环境因素五个方面人手构建了以人失误为主因的变电所检修事故模型,基于该模型提出了有效、合理的避免或减少变电所检修事故的五点对策措施。以期能为变电所检修事故的预防起到积极的指导作用。     

基于AHP-SLIM的航空器维修人误概率确定

人误是造成民用航空维修差错的主要因素。由于缺少实际的数据,对航空维修行业人为失误发生的规律进行研究是必要的,但是规律研究主要依赖于该领域专家的判断,很难确保一致性。为了克服这个困难得到更加准确的评估,本文将层次分析法同成功似然函数结合起来估计造成飞机/发动机/附件损坏的人误概率。该方法确定了航空器维修人员的安全态度、知识和技能、计划和监管、信息沟通等因素,对人误的影响程度以及飞机/发动机/附件损坏中常见人误的发生概率。计算结果表明,操作/试验时最容易发生飞机/发动机/附件损坏,并且提出加强组织和监管、严格按章办事等解决措施。     

基于CREAM和贝叶斯网络的航空维修人为差错概率预测

航空维修差错不仅严重威胁着飞行安全,同时也会增加航空公司的维修成本。针对航空维修人员发生差错成因的复杂性以及历史事故数据缺乏的情况下,将人因可靠性与失误分析方法（CREAM）和贝叶斯网络（BN）相结合,提出一种改进的维修差错分析模型。根据维修任务构建相应的贝叶斯网络模型,为各子节点设置条件概率表（CPT）;基于维修基地的实际维修环境,对行为形成因子（PSFs）进行评估,得到共同绩效条件（CPCs）的水平;利用各CPC因子下各个行为功能失效模式的权重因子,对各认知活动进行失效概率的修正;将修正概率作为贝叶斯网络根节点的输入,利用推理机制,得到差错发生概率。通过案例分析和计算,验证了所述方法的可行性和有效性。     

一种基于贝叶斯网络的机务维修差错调查模型算法

提出一种基于贝叶斯网络的机务维修差错调查模型算法,根据已经建立的机务人为诱因导致事故/事故征候模型,利用贝叶斯原理编程实现了该算法。利用该算法对中国民航飞行学院2001-2011年的机务人为有引导的事故/事故征候依次进行分析并验证,得到了相应的事故诱因概率排序。该算法克服了样本空间不足,在事故发生以后能够在引入其他证据的情况下根据以前的经验概率得到新的事故诱因概率排序,为民航机务维修差错调查提供了可靠的技术支持。     

Significant human risk factors in aircraft maintenance technicians

We examined significant human risk factors in aircraft maintenance technicians (AMTs) in the airline industry. We conducted an empirical study of Taiwan’s airlines to determine these risk factors and to illustrate how a quantifiable evaluation approach integrates experts’ opinions about the relative importance of risk factors. We developed an expert questionnaire and modified the human factors SHELL model to categorize the risk factors that we derived from the literature and the opinions of 107 senior experts. The empirical results showed that there are nine significant risk factors out of 77 preliminary and 46 primary risk factors. The results also provided support for the approach and model presented in this work, demonstrating that they are both strategically effective and practically acceptable. Analyzing and ranking the significant risk factors for AMTs in this fashion may help airlines to better focus on their major operational and managerial weaknesses in order to improve maintenance operations under the condition of limited resources.     

认知控制模式下的CREAM方法概率量化

研究了人因可靠性分析(Human Reliability Analysis,HRA)中人为差错概率的量化.首先,介绍了认知可靠性与差错分析方法(Cognitive Reliability and Error Analysis Method,CREAM)中基本法的基本理论,讨论了两种概率化认知控制模式的确定方法——贝叶斯网络法和模糊逻辑法,强调了概率化认知控制模式下量化人为差错概率的必要性.然后,在分析认知模式下人为差错概率分布的基础上,通过理论推导,构建了概率化认知控制模式下人为差错概率的量化方法.为了提高计算效率,提供了人为差错概率的蒙特卡洛仿真算法.最后,通过实例,演示了方法的使用过程,并证明了方法的有效性.     

Managing error on the open road: The contribution of human error models and methods

Despite the provision of various theoretical models and error management methods, error and error-causing conditions remain omnipresent within road transport. This article presents a review of human error models and selected error management approaches, and their applications in a road transport context. The review indicates that such applications, although extant, are limited, and that, compared to other domains, the impact of the models and methods discussed has been only minimal. Reasons for this are discussed, and potential ways in which the models and methods can contribute to road safety are proposed. In conclusion, it is argued that human error models and management methods, although already well integrated within most safety critical domains, still have much to offer to the enhancement of road safety. Further, it is argued that advances in the area, in terms of theoretical and methodological development and validation, are still to be made, and that applications of the error management methods discussed are required to enable such advances.     

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.     

民航人因失误分类框架

人因失误分类是否系统、完整及对人误描述是否一致直接影响人误分析的结果。本文对民航中主要几种人误分析方法进行了详细评述,指出其在考虑人的认知过程和行为外在表现形式方面的不足。在对现有人误理论模型和人误分类方法详细分析的基础上,提出了民航人误分类框架。框架由人的行为过程的四个阶段“获取信息-分析处理信息-决策／计划-执行”和八类人误模式及相应的子模式构成。行为阶段与人误模式可针对具体活动进行组合,框架的使用具有灵活性。框架对保证民航中人误辨识结果的规范性和准确性具有重要意义。     

Dynamic management of human error to reduce total risk

Safety management in companies at the limit of risk criteria must be implemented in order to survive in the very aggressive and competitive environment of modern society. It implies that the risk in process industries is crossing the limit of safe practices. Most major accidents consist of human errors and mechanical component failures, and cannot be explained by a stochastic coincidence of independent events. This work focuses on the coincidence of human error and mechanical failure to introduce a concept of dynamic management of human error. By the dynamic management of human error during a short period, when a mechanical component is temporarily unavailable during periodic testing or maintenance, the probability of a major accident may be reduced significantly without additional investment on improving safety. For the periodically-tested standby component, the majority of total average unavailability of the component may be recognized by operators or workers as well as maintenance mechanics. During this short period, an appropriate dynamic management of human error for improving human performance temporarily may be very effective in reducing total risk in industries. The dynamic management of human error may be a useful method to prevent loss effectively in the process industries     

危险品集装箱堆场人因失误概率量化方法研究

由于人因失误是引发危险品集装箱堆场事故的主要原因,特别以成功似然指数法为框架研究了危险品集装箱堆场人因失误概率的量化方法。考虑了影响因子的主观特性,重点结合认知可靠性与失误分析方法对成功似然指数法进行修正,确定了培养与组织管理、同时出现的目标数量等6项行为形成因子。通过建立熵权法、模糊集合理论与专家判断的融合实现人因失误概率的计算。最后,用算例验证了方法的有效性,结果表明,本方法不但可将测算精度控制在有效区间(0,0.059 5),而且相较其他方法将危险系数降低了6.97%。针对危险品集装箱堆场管理这类高危行业,较高的人因失误率有利于风险辨识和风险预防。     

基于人因失误分析的医院电气安全管理研究

医院是重点用电单位,用电的安全性和供电可靠性都比较高,但因不可抗力、供电系统故障、医院管理问题、人为失误等方面的原因,仍存在发生各类电气突发事件的风险。其中,由人的误操作或不安全行为因素而诱发的电气方面的突发事件已成为医院非医疗事故的主要原因。文章针对医院电气安全操作方面的人因失误,从个人和组织两个角度进行了失误原因的分析,认为人的失误既受个体因素的影响,也受环境、制度和管理水平的影响。在此基础上,提出完善相关规章制度建设、加强教育与培训等,从组织制度建设、人员技术素质提高等方面,提出预防与减少人因失误的措施与方法,提高供配电质量,为医院医疗工作提供有效的电气安全后勤保障。     

页岩气压裂作业人因失误结构化辨识方法研究

为提高页岩气压裂作业人因失误辨识结果的全面性和针对性,建立一种结构化的人因失误辨识方法。通过概括辨识阶段的作业流程,建立作业人员行为模型,概述作业人员的行为阶段。利用筛选出的引导词辨识行为阶段人因失误。将该方法应用于页岩气压裂过程的替液阶段。结果表明,用引导词能明确辨识方向,减少头脑风暴时间以及对专家知识的依赖;辨识过程的动态调整能改善认知可靠性,使更多人因失误模式(与传统CREAM方法相比)被辨识出来。     

The criminalization of human error in aviation and healthcare: A review

This review explores the social causes and psychological and organizational consequences of the criminalization of human error in aviation and healthcare. Increasing prevalence of criminal prosecution is seen as a threat to the health and safety of employees and entire safety–critical systems in many industries, but initiatives to counter or mitigate the trend are local and haphazard. Social causes such as a greater societal risk consciousness and intolerance of failure are examined, as well as organizational consequences for disclosure and incident reporting. Psychological consequences of the criminalization of human error are evaluated in terms of employee ill-health, an area that is under-investigated. The criminalization of professional mistakes seems to be an increasingly prevalent phenomenon at the intersection of safety work, sociology, criminology and legal as well as social justice. This paper reviews possible research directions into the criminalization of professional mistake in aviation and healthcare, in the hope of stimulating debate and eventually legitimating it as a topic of study in its own right.     

A review of medical error taxonomies: A human factors perspective

Although a large number of medical error taxonomies have been published, there is little evidence to suggest that these taxonomies have been systematically compared. This paper describes a study comparing 26 medical error taxonomies using a human factors perspective. The taxonomies were examined to determine if they classified systemic factors of medical errors and if they utilized theoretical error concepts in their classifications. Scope of classification was also examined. It was found that two-thirds of the taxonomies classified systemic factors of medical errors and only a third utilized theoretical error concepts. Medical error taxonomies based on theoretical error concepts were more likely to be generic in applicability and also more likely to classify systemic factors and psychological error mechanisms of medical errors. In addition to terminology, the medical error taxonomies also varied in terms of domain-specificity, granularity, and developmental process. Different medical error taxonomies provide different information; how these differences affect medical error management needs to be investigated.     

Fuzzy logic-based approach for identifying the risk importance of human error

In the system reliability and safety assessment, the focuses are not only the risks caused by hardware or software, but also the risks caused by “human error”. There are uncertainties in the traditional human error risk assessment (e.g. HECA) due to the uncertainties and imprecisions in Human Error Probability (HEP), Error-Effect Probability (EEP) and Error Consequence Severity (ECS). While fuzzy logic can deal with uncertainty and imprecision. It is an efficient tool for solving problems where knowledge uncertainty may occur. The purpose of this paper is to develop a new Fuzzy Human Error Risk Assessment Methodology (FHERAM) for determining Human Error Risk Importance (HERI) as a function of HEP, EEP and ECS. The modeling technique is based on the concept of fuzzy logic, which offers a convenient way of representing the relationships between the inputs (i.e. HEP, EEP, and ECS) and outputs (i.e. HERI) of a risk assessment system in the form of IF–THEN rules. It is implemented on fuzzy logic toolbox of MATLAB using Mamdani techniques. A case example is presented to demonstrate the proposed approach. Results show that the method is more realistic than the traditional ones, and it is practicable and valuable.     

高处坠落事故的人因失误与干预策略研究

为系统分析导致高处坠落人因事故的产生机理,通过统计152起建筑工程高处坠落事故的调查与分析报告,从组织影响、安全监管、不安全行为前提条件和不安全行为等4个层次,辨识影响高处坠落事故的人为失误因素,修订人为因素分析与分类系统框架（HFACS）。设计高处坠落人因失误调查问卷,开展一线高处作业人员问卷调查,建立高处坠落人因失误结构方程模型,对导致高处坠落事故的人为失误因素进行路径分析。结果表明:各潜在因素间均呈正相关,且高处坠落人因失误事故的关键路径为资源管理不到位→安全监督培训不充分→班组管理不良→操作违规。综合各因素间相关性,提出了针对性的预防高处坠落事故的人因干预策略。     

基于层次分析法的人因失误分析技术

文章在分析人为失误致因的基础上,运用层次分析法（AHP）原理,建立了人为失误致因的层次结构模型,通过对AHP模型的求解,对影响人因失误因素的相对重要性进行了排序,并对排序结果进行了一致性检验,确定了评价因子的影响力排序,从而找出了影响人因失误的关键性因素和重要因素,为控制和减少人因事故制定有效对策提供了参考依据。