人误屏障分析技术

在复杂工业系统中,屏障是预防与减少人误的有效方法,一旦屏障失效,事故就有可能发生。笔者从屏障的概念与屏障分析入手,分析了实体屏障和管理屏障两类基本的屏障,介绍了屏障分析的6个步骤即辨识危险和目标、辨识屏障、评估屏障是否失效、弄清原因、评估与决定、制定方案及其分析案例,进行创建和维持屏障的方案分析,建立纠正行动计划的屏障方案,指出有效使用屏障分析技术来减少人误的几个场合以及屏障分析的局限性。

Analytical Techniques of Human Error Barrier

Barrier in complicated industrial system is the most effective measure for preventing and reducing human error. Accident would not probably be avoided once barrier fails. Beginning with concept of barrier and barrier analysis, two basic types of barriers are analyzed: the physical and management barriers. Barrier analysis in six steps is introduced, i.e. to identify the hazard and targets, to identify barriers, to evaluate whether each barrier is effective or not, to determine why it is failed, the role of each barrier is evaluated to determine whether it is a direct, contributing, root and/or programmatic cause, and to work out protocol and case analysis example for illustration. The protocols creating and maintaining barriers are analyzed and barrier protocols of corrective action plans are put forward. Occasions effectively using barrier analytical techniques to reduce human error and the limitation of barrier analysis are pointed out.