人误因素树构建技术研究

运用人误因素辨识多视图法进行因素辨识,建立了详细的因素辨识表;把人的行为分为5个阶段,即系统状态监测阶段,目标分析阶段,方案确定阶段和行为执行阶段.分别分析各个阶段可能的人误原因及模式;以组织视图为例,根据因素辨识和人误原因及模式分析结果,阐述人误因素树的构建过程,最终得到了1个完整的人误因素树.     

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.     

库存弹药事故人误危险性分析与评估模型研究

针对库存弹药安全的特殊性,提出库存弹药事故人为失误的定义,并从个体角度分析人误事件发生的机理。根据人为失误的不同主体,从管理决策、组织和勤务处理、操作两个方面构建了29个人误危险性的评价指标及相应的评判标准;综合考虑生理、心理、知识与技能、设备、环境、监督与管理等6类危险性抵消因子对人误危险性的影响;进而建立了库存弹药事故人误危险性的理论评估模型。研究结果表明:人为失误属于弹药仓储安全管理中的一类特殊危险源,人误评估指标体系和评估模型的构建过程应充分考虑人自身条件以及内、外部环境等因素的综合影响;同时研讨了人为失误危险性分析和评估模型存在的问题,并从发展人误数据采集技术、完善人误事故报告制度以及建立人误数据库等方面,指出下一步的研究重点。     

基于BN-CREAM的深水井控压井作业风险诱因研究

深水井控压井作业是有效控制溢流演化为井喷事故的二级井控工艺屏障。为提高深水井控压井作业可靠性,采用 BN-CREAM方法对其风险诱因进行研究。结合深水井控压井作业特点,考虑共因失效等因素,采用贝叶斯网络方法建立深 水井控压井作业风险演化模型。应用人因可靠性分析CREAM法计算深水压井人因失误先验概率,参考海洋可靠性数据手 册OREDA确定深水井控设备失效先验概率。依托贝叶斯网络的逆向推理能力辨识压井作业的主要风险节点,从而实现对 深水井控压井作业风险诱因的有效预测和评估。研究表明:深水井控压井作业共包含6个关键风险根节点,且压井作业人 因可靠性要低于设备可靠性;3级子节点“压井方法选择不合理”对深水压井作业的成功起到至关重要的作用,需进一 步开展风险分析研究。     

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。     

含硫气井井筒完整性风险评价研究

针对含硫气井开发过程中井筒完整性失效风险,建立了含硫气井风险评价模型。采用Bow-tie模型将井筒完整性的失效形式分为水力屏障失效、实体屏障失效和操作管理屏障失效3个方面,确定了含硫气井井筒完整性失效的28个风险因素;基于层次分析法定量确定了各风险因素的权重,通过风险矩阵法评估了风险因素发生的可能性与严重程度,实现了对井筒完整性风险等级的划分。将以上方法对某含硫气井进行了应用,确定了该井的风险等级及主要风险因素。研究结果表明:建立的风险评价模型能够对含硫气井井筒完整性进行评价,确定风险等级。该方法的应用有助于降低含硫气井的事故风险,可为含硫气井完整性现场管理提供参考。     

发电企业人因失误分析及其预防控制措施研究

为预防和减少人因失误导致的事故,通过分析不同类型人因失误,找出导致人因失误的根本原因,运用4M屏障理论,找出失效屏障并提出修补的方法。发电企业应发挥安全文化的导向、凝聚、辐射和同化等功能,引导和规范安全生产活动,充分运用防人因失误工具,在事件发生前防止人因失误的发生。结合案例分析,探讨减少人因失误工具,包括明星自检、质疑的态度、3向交流、遵守程序、监护、独立验证、工前会、不确定时暂停、工作交接、他检等。研究结果表明：使用减少人因失误工具,强化安全教育培训、改善人机安全状况、强化安全管理,构建基于4M屏障理论的多重预防体系,可以有效斩断事故链或堵塞屏障漏洞,从而避免事故发生。展望未来,构建卓越安全文化是实现被动安全转变为主动安全的核心逻辑,通过提升全员的安全观念、意识、思想、态度、知识、技能,从而实现全员在安全工作中的高度自觉和自律。     

复杂工业系统中人因失误根本原因分析

在现代大规模复杂人 -机 -环境系统中 ,人因失误诱发的故障或事件呈上升趋势。人因事件的根本原因分析 ,对于防范复杂系统中事故的发生是非常必要的。人因事件根本原因的分析包括 :需要分析的人因事件的确定 ;对事实进行调查 ,分析调查结果 ;确定根本原因 ;制定纠正措施 ;完成最终报告。人因事件的分析最终需要找出失效屏障并提出修补的方法 ,笔者采用事件与原因因子分析技术来进行分析。在分析过程中 ,需要绘出事件和原因因子图 (E&CF图 ) ,而E&CF图可以显示出从开始到结束全过程中事件发生的正确次序 ,通常包括失效屏障 ,预先存在的条件、次级事件、不恰当的动作和形成事件的原因因子。形成人因事件的原因因子在复杂工业系统中 ,可以分成 12个部分。笔者给出了核电厂蒸汽发生器 (SG)主给水阀门泄漏的人因事件的分析实例 ,确认了该实例中失效的屏障和事件的根本原因并提出了纠正措施。     

基于模糊ANP的海底管道失效风险综合评价

为更准确地评价海底管道失效风险,综合采用德尔菲法、模糊理论、网络分析法(ANP)和模糊综合评价法,首先,依据专家意见与事故统计数据,从腐蚀、自然因素、第三方破坏、材料等4个方面辨识管道失效风险源;其次,邀请领域专家评估管道失效概率,判断各风险因素相互影响的重要度;然后,通过模糊理论处理评估信息,使用Matlab软件完成极限超矩阵和全局权重向量的编程计算;最后,以南海荔湾某在役输气管道为例,进行模糊综合评估。结果表明:该在役管道的风险评价等级为较低;第三方破坏与腐蚀是海底管道失效的主要原因,与事故统计数据基本一致,验证了基于模糊ANP的失效风险综合评估的合理性。     

高速铁路信号系统的安全管理评价研究

高速铁路信号系统要通过安全管理来保障其开发与运行中的安全相关活动符合系统安全计划的要求。为了评估安全管理活动的可信性,提出基于系统安全分析技术的安全管理评价方法。通过建立安全管理流程与系统安全功能相关联的概念模型,使用安全文化危险与可操作性研究(SCHAZOP)辨识出安全管理流程中的行为偏差,基于失效传导转换符号(FPTN)建立管理角色的安全文化失效模型,最终将管理行为失效模式转换成组件故障树作为安全管理评价证据。研究结果表明,安全管理行为偏差体现了信号系统开发与运营过程中的安全文化特征;辨识与分析安全文化失效,为信号系统安全管理活动的可信性提供了评价依据。     

Dynamic-risk-informed safety barrier management: An application to cost-effective barrier optimization based on data from multiple sources

An integrated approach for performance assessment and management of safety barriers in a systemic manner is needed concerning the prevention and mitigation of major accidents in chemical process industries. Particularly, the effects of safety barriers on system risk reduction should be assessed in a dynamic manner to support the decision-making on safety barrier establishments and improvements. A simulation approach, named Simulink-based Safety Barrier Modeling (SSBM), is proposed in this paper to conduct dynamic risk assessment of chemical facilities with the consideration of the degradation of safety barriers. The main functional features of the SSBM include i) the basic model structures of SSBM can be determined based on bow-tie diagrams, ii) multiple data (periodic proof test data, continuous condition-monitoring data, and accident precursor data) may be combined to update barrier failure probabilities and initiating event probabilities, iii) SSBM is able to handle uncertainty propagation in probabilistic risk assessment by using Monte Carlo simulations, and iv) cost-effectiveness analysis (CEA) and optimization algorithms are integrated to support the decision-making on safety barrier establishments and improvements. An illustrative case study is demonstrated to show the procedures of applying the SSBM on dynamic risk-informed safety barrier management and validate the feasibility of implementing the SSBM for cost-effective safety barrier optimization.     

Application of machine learning technique for optimizing roadside design to decrease barrier crash costs,a quantile regression model approach

Introduction: In-transport vehicles often leave the travel lane and encroach onto natural objects on the roadsides. These types of crashes are called run-off the road crashes (ROR). Such crashes accounts for a significant proportion of fatalities and severe crashes. Roadside barrier installation would be warranted if they could reduce the severity of these types of crashes. However, roadside barriers still account for a significant proportion of severe crashes in Wyoming. The impact of the crash severity would be higher if barriers are poorly designed, which could result in override or underride barrier crashes. Several studies have been conducted to identify optimum values of barrier height. However, limited studies have investigated the monetary benefit associated with adjusting the barrier heights to the optimal values. In addition, few studies have been conducted to model barrier crash cost. This is because the crash cost is a heavily skewed distribution, and well-known distributions such as linear or poison models are incapable of capturing the distribution. A semi-parametric distribution such as asymmetric Laplace distribution can be used to account for this type of sparse distribution. Method: Interaction between different predictors were considered in the analysis. Also, to account for exposure effects across various barriers, barrier lengths and traffic volumes were incorporated in the models. This study is conducted by using a novel machine-learning-based cost-benefit optimization to provide an efficient guideline for decision makers. This method was used for predicting barrier crash costs without barrier enhancement. Subsequently the benefit was obtained by optimizing traffic barrier height and recalculating the benefit and cost. The trained model was used for crash cost prediction on barriers with and without crashes. Results: The results of optimization clearly demonstrated the benefit of optimizing the heights of road barriers around the state. Practical Applications: The findings can be utilized by the Wyoming Department of Transportation (WYDOT) to determine the heights of which barriers should be optimized first. Other states can follow the procedure described in this paper to upgrade their roadside barriers.     

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。     

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。     

A dynamic Bayesian networks modeling of human factors on offshore blowouts

An application of dynamic Bayesian networks for quantitative risk assessment of human factors on offshore blowouts is presented. Human error is described using human factor barrier failure (HFBF), which consists of three categories of factors, including individual factor barrier failure (IFBF), organizational factor barrier failure (OFBF) and group factor barrier failure (GFBF). The structure of human factors is illustrated using pseudo-fault tree, which is defined by incorporating the intermediate options into fault tree in order to eliminate the binary restriction. A methodology of translating pseudo-fault tree into Bayesian networks and dynamic Bayesian networks taking repair into consideration is proposed and the propagation is performed. The results show that the human factor barrier failure probability only increases within the first two weeks and rapidly reaches a stable level when the repair is considered, whereas it increases continuously when the repair action is not considered. The results of mutual information show that the important degree sequences for the three categories of human factors on HFBF are: GFBF, OFBF and IFBF. In addition, each individual human factor contributes different to the HFBF, those which contribute much should given more attention in order to improve the human reliability and prevent the potential accident occurring.     

Influence of the shape of mitigation barriers on heavy gas dispersion

Regasification plants have become an emerging risk because their numbers are increasing and concern from the general population towards these systems has grown. Consequently, there is increased interest in investigating the effect of mitigation measures to limit the impact of large accidents on the population living close to the plant. Among the various possible mitigation measures, physical barriers present several advantages; however, it is known that the necessary barrier height can became impracticably large to be effective in mitigating the consequences of a large LNG release. Therefore, computational fluid dynamics models were used in this work to analyze the performance of mitigation barriers with different shapes to investigate the possibility of increasing mitigation barrier efficiency by simply changing the main geometrical characteristics of the barrier such as roughness, battlements, or even holes.     

Safety performance evaluation of cable median barriers on freeways in Florida

Objective: This article aims to evaluate the safety performance of cable median barriers on freeways in Florida.

Method: The safety performance evaluation was based on the percentages of barrier and median crossovers by vehicle type, crash severity, and cable median barrier type (Trinity Cable Safety System [CASS] and Gibraltar system). Twenty-three locations with cable median barriers totaling about 101 miles were identified. Police reports of 6,524 crashes from years 2005–2010 at these locations were reviewed to verify and obtain detailed crash information. A total of 549 crashes were determined to be barrier related (i.e., crashes involving vehicles hitting the cable median barrier) and were reviewed in further detail to identify crossover crashes and the manner in which the vehicles crossed the barriers; that is, by either overriding, underriding, or penetrating the barriers.

Results: Overall, 2.6% of vehicles that hit the cable median barrier crossed the median and traversed into the opposite travel lane. Overall, 98.1% of cars and 95.5% of light trucks that hit the barrier were prevented from crossing the median. In other words, 1.9% of cars and 4.5% of light trucks that hit the barrier had crossed the median and encroached on the opposite travel lanes. There is no significant difference in the performance of cable median barrier for cars versus light trucks in terms of crossover crashes. In terms of severity, overrides were more severe compared to underrides and penetrations. The statistics showed that the CASS and Gibraltar systems performed similarly in terms of crossover crashes. However, the Gibraltar system experienced a higher proportion of penetrations compared to the CASS system. The CASS system resulted in a slightly higher percentage of moderate and minor injury crashes compared to the Gibraltar system.

Conclusions: Cable median barriers are successful in preventing median crossover crashes; 97.4% of the cable median barrier crashes were prevented from crossing over the median. Of all of the vehicles that hit the barrier, 83.6% were either redirected or contained by the cable barrier system. Barrier crossover crashes were found to be more severe compared to barrier noncrossover crashes. In addition, overrides were found to be more severe compared to underrides and penetrations.     

Human error risk analysis in offshore emergencies

Human factors play an important role in the completion of emergency procedures. Human factors analysis is rooted in the concept that humans make errors, and the frequency and consequences of these errors are related to work environment, work culture, and procedures. This can be accounted for in the design of equipment, structures, processes, and procedures. As stress increases, the likelihood of human error also increases. Offshore installations are among the harshest and most stressful work environments in the world. The consequences of human error in an offshore emergency can be severe.A method has been developed to evaluate the risk of human error during offshore emergency musters. Obtaining empirical data was a difficult process, and often little information could be drawn from it. This was especially an issue in determining the consequences of failure to complete muster steps. Based on consequences from past incidents in the offshore industry and probabilities of human error, the level of risk and its tolerability are determined. Using the ARAMIS (accidental risk assessment methodology for industries) approach to safety barrier analysis, a protocol for choosing and evaluating safety measures to reduce and re-assess the risk was developed. The method is assessed using a case study, the Ocean Odyssey incident, to determine its effectiveness. The results of the methodology agree with the analysis of survivor experiences of the Ocean Odyssey incident.     

Investigating the effect of geometric dimensions of median traffic barriers on crashes: Crash analysis of interstate roads in Wyoming using actual crash datasets

IntroductionDespite the numerous safety studies done on traffic barriers’ performance assessment, the effect of variables such as traffic barrier’s height has not been identified considering a comprehensive actual crash data analysis. This study seeks to identify the impact of geometric variables (i.e., height, post-spacing, sideslope ratio, and lateral offset) on median traffic barriers’ performance in crashes on interstate roads.MethodGeometric dimensions of over 110 miles median traffic barriers on interstate Wyoming roads were inventoried in a field survey between 2016 and 2018. Then, the traffic barrier data collected was combined with historical crash records, traffic volume data, road geometric characteristics, and weather condition data to provide a comprehensive dataset for the analysis. Finally, an ordered logit model with random-parameters was developed for the severity of traffic barrier crashes. Based on the results, traffic barrier’s height was found to impact crash severity.ResultsCrashes involving cable barriers with a height between 30″ and 42″ were less severe than other traffic barrier types, while concrete barriers with a height shorter than 32″ were more likely involved with severe injury crashes. As another important finding, the post-spacing of 6.1–6.3 ft. was identified as the least severe range in W-beam barriers.Practical applicationsThe results show that using flare barriers should reduce the number of crashes compared to parallel barriers.