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。

Analysis of Fundamental Causes of Man-made Errors in Complex Industrial System

In modern large-scale complex man-machine-environment system, failures and events caused by human errors show an increasing trend. Analysis on fundamental causes of man-made errors is necessary in preventing accidents. The analysis includes determination of the man-made event to be analyzed, fact investigation, analysis on investigation results, determination of fundamental causes, deciding the rectifying measures and accomplishing the finalized report. The final aim of the analysis is to find out the failure barrier and the way of remedy. The authors conduct this analysis by event & cause factor (E&CF) chart. In the analysis, E&CF chart needs to be drawn to show the correct sequence of the happenings in whole process, including failure barrier, pre-conditional factors, sub-events, inappropriate actions and the final human elements forming 12 categories of cause factors. The authors present an analysis case of main water supply valve leakage of the steam generator in a nuclear power plant .The failure barrier, the fundamental causes of the event are also presented, and then the rectification measures are suggested.