组织人因失误分析

工业生产中，人因失误已成为最主要的事故源之一。人因失误研究越来越受到重视，研究方向已从个体失误向组织人误发展。文章论述了组织人因失误产生的过程，辨识出组织人因失误行为形成因子(PSFs)并归纳成为组织人因失误的4大类12组原因因素，提出了预防组织人因失误的基本对策。     

人误模式与原因因素分析

将人误模式分为显现型和潜在型两类.显现型人误模式主要体现在时间、行为、目标、顺序四维时空特性上,而潜在的人误模式是基于认知过程与组织的,需要从微观与宏观两方面对其进行分类.影响人为失误的原因归结为个人、技术、组织、环境四类因素.将人误作为一个事件来进行分析,构建了概念上的人误原因层次诊断模型,它包括原因主因素、子因素和子子因素层等.以人误模式为切入点,对这些因素的诊断采用了人误原因的回溯性分析方法,具体过程为:一般行为条件描述-确定可能的人误模式-确定可能的人误原因因素-匹配判断.     

基于行为形成因子相关性的人因失误影响研究

生产过程中,行为形成因子会对人因失误产生不可忽略的作用。在行为形成因子诱发人因失误的过程中,其他行为形成因子也会对诱发过程产生影响。本文基于这种影响作用,对行为形成因子影响人因失误的程度进行了量化,求解得出了人因失误的概率,并进行了实验验证。     

应激情景下数字化系统操纵员认知行为失误分析

人在应激情景下的认知行为特点是第二代人因可靠性分析方法(HRA)的重点研究领域.应激因子是许多人因可靠性分析模型重点考虑的行为形成因子(PSFs)之一.本文提出基于认知资源理论的应激因子作用模型作为统一的分析框架,初步探讨了应激因子对人的认知行为失误的作用机制.运用该模型从认知资源的角度分析了数字化主控室的新特征可能导致的人因失误.     

人因失误原因因素控制模型及屏障分析

就复杂技术系统中可能出现的人因失误在宏观层次上做了探讨,并对造成人因失误的原因因素进行了分析.从个体层、班组层、组织层3个层次分析人因失误的原因因素,建立了人因失误原因因素控制模型.基于此模型对研究的系统进行屏障分析,建立了屏障分析层次模型.     

人误研究的组织定向

传统的人误研究为个体定向。９０年代以来,逐渐形成了以分析事故的组织因素为主的组织定向。Ｒｅａｓｏｎ首先分析了复杂系统的新特征,提出复杂系统中事故大新因果模型。这个模型特别提出潜在的管理错误系统安全的威胁。Ｗｉｌｐｅｒｔ和Ｑｖａｌｅ主编的《危险工作系统的可靠性与安全》一书汇集了欧美学者对事故中组织错误的类型及作用的分析,成为人误研究的组织定向里程碑。     

人因失误根原因分析方法与应用

人因失误是复杂人机系统失效和事故的最重要的根源之一.文章介绍了人因失误根原因分析方法的基本步骤,描述了人因事件的基本故障模式和屏障分析以及人因失误的根本原因分析的实施程序;并在此基础上提出了以安全管理与教育和实体屏障并重的多重防御体系来预防人因事件,并以衡阳纺织机械厂一个人因事件示例.     

基于改进成功拟然指数法的管制员调配飞行冲突的人因失误概率研究

目的为了研究管制员在调配飞行冲突时的人因失误的可能性,探究造成其人因失误的行为形成因子(Performance Shaping Factors,PSF),确定其在PSF影响下的人因失误概率。方法首先结合实际情况总结归纳了八种管制工作中可能出现的人因失误,并通过调查和计算得到每个人因失误的相对可靠度;应用认知可靠性与差错分析方法(Cognitive Reliability and Error Analysis Method,CREAM)提取并改进行为因子(PSF),并通过模糊层次分析法计算各个行为因子的归一化权重,然后计算得到SLIM中的成功似然指数(Success Likelihood Index,SLI);最后通过Delphi法确定端点概率值,进而求得管制员人因失误的概率。结果本文总结归纳得到了八种管制员人为失误,并采用德尔菲法(Delphi)与成功似然指数法(Success Likelihood Index Method,SLIM)相结合的方法分析管制员调配飞行冲突时的人因失误概率。结论本文应用改进的SILM方法定量与定性的计算了管制员调配飞行冲突时的人因失误概率,符合实际情况,在目前管制员人因失误研究缺乏数据和模型的情况下,具有一定指导意义。     

人误因素树构建技术

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；把人的行为分为系统状态监测、状态分析、目标分析、方案确定和行为执行5个阶段，分别各个阶段可能的人误原因及模式；根据因素辨识和人误原因及模式，分析结果，以组织视图为例阐述人误因素树的构建过程，最终得到了一个完整的人误因素树。     

人误模式、影响与严重度分析方法

人因失误已成为复杂系统最主要的事故源之一，而人误分析技术存在着缺乏一致性和使用困难等问题。本文将故障模式，影响与严重度分析方法进行人因特征化改造，提出人误模式，影响与严重度分析方法，规范化地分析人因失误的故障模式与影响，根本原因及严重度和相应的人因失误防范策略。     

人机系统可靠性设计研究进展

目的 研究人机系统可靠性设计理论。方法 通过对可靠性概念的描述,进而对机械可靠性、人的可靠性、人机系统可靠性的研究现状、主要分析方法及应用等方面的文献进行梳理与综合分析。初步构建了人机系统可靠性设计研究框架。结论 指出人机系统可靠性设计的未来发展趋势,为该领域进一步的研究提供参考。     

基于非驾驶任务的智能座舱出错因子提取与分析

目的 针对当前汽车智能座舱系统逐渐由驾驶为主转变为关注驾驶与舱内体验两方面的趋势,通过提取并分析驾驶员的人因差错,探讨智能座舱人机交互界面的设计分析方法。方法 基于实车操作实验,选取了10个常见的智能座舱非驾驶任务,对其交互过程中的出错因子进行了提取,结合错误背后的认知机制,形成智能座舱错因聚类,并横向对比了三款不同座舱界面的出错因子复现频率。结果 在认知框架的不同模块中,出错因子的复现频率存在显著差异。基于认知理论,对错因背后的设计表征进行了深入归纳与分析。结论 将错因分析研究方法引入智能座舱界面的设计研究中,能够更加有效地分析驾驶员对界面信息的认知状态,以及其对驾乘体验的影响,为智能座舱的人机交互设计研究提供了参考依据。     

基于人因指数的人机界面评价

目前人机界面的评价大都依据个人的感觉、经验。对人机界面评价的理论、方法尚处于探讨之中。该文在主、客观评价基础上提出了人机界面"人因指数"综合评价指标,建立了基于灰色聚类分析的人机界面"人因指数"综合评价模型。结合某型潜艇综合显控台进行了人机界面的综合评价。     

Error analysis and applications in transportation systems

This paper presents an overview of the field of error analysis. Section 1 shows why discussions about human error are relevant for societal safety. With regard to safety research, it is important to predict abnormal events. At the machine side, reliability studies proved their value, but to predict failures in the human factor has been shown to be very difficult. Therefore, problems in how to define the notion of human error (Section 2) and how to classify different types of error (Section 3) are discussed. Some researchers started to use systematical classifications of human error types based on a recent, hierarchical model of human task performance. The outline of the model is presented. Examples of error analysis studies from the field of transportation research (Section 4) provide some basic suggestions on how to reduce error rates. Some conclusions on error control are given in Section 5. The responsibility of managers and system designers in this respect is strongly emphasized.     

Using finite state automata (FSA) for formal modelling of affordances in human-machine cooperative manufacturing systems

Modelling complex systems poses significant challenges on how one represents the system components and interactions among them. In order to provide a systematic approach to represent human participation as a part of a dynamic system, this paper presents a formal automata model of human-machine cooperative systems that incorporates human capabilities with respect to system conditions. Specifically, we propose a control model for human-involved shop floor systems based on discrete event-based systems (DES) and an environmental concept known as an affordance. When modelling human-involved systems where a human operator is considered a crucial system component, it is necessary to analyse the model complexity that increases significantly due to a human's behavioural patterns. From the perspective of the temporal and physical state domains a human operator's behaviour is usually limited by attention and resource constraints. We investigate these limitations and map them into constrained system affordances, and then construct a formal human-machine cooperative model based on the finite state automaton (FSA) model. The proposed model can provide a framework to combine human activities into systems operations in consideration of human's effectivities and system affordances. A detailed application example is provided to illustrate that the proposed model can effectively be applied to manufacturing control systems.     

Application of condition-based HRA method for a manual actuation of the safety features in a nuclear power Plant

A practical approach to develop a more realistic fault-tree model with a consideration of various conditions endured by a human operator is proposed. In safety-critical systems, the generation failure of an actuation signal is caused by the concurrent failures of the automated systems and an operator action. These two sources of safety signals are complicatedly correlated. The failures of sensors or automated systems will cause a lack of necessary information for a human operator and result in error-forcing contexts such as the loss of corresponding alarms and indications. It is well known that the error-forcing contexts largely affect the operator's performance. An automated system which consists of multiple processing channels and complex components is also affected by the availability of the sensors. This paper proposes a condition-based human reliability assessment (CBHRA) method in order to address these complicated conditions in a practical way. We apply the CBHRA method to the manual actuation of the safety features such as a reactor trip and auxiliary feedwater actuation in Korean Standard Nuclear Power Plants. Even the human error probability of each given condition is simply assumed, the application results prove that the CBHRA effectively accommodates the complicated error-forcing contexts into the fault trees.     

A model-based framework for the analysis of team communication in nuclear power plants

Advanced human-machine interfaces are rapidly changing the interaction between humans and systems, with the level of abstraction of the presented information, the human task characteristics, and the modes of communication all affected. To accommodate the changes in the human/system co-working environment, an extended communication analysis framework is needed that can describe and relate the tasks, verbal exchanges, and information interface. This paper proposes an extended analytic framework, referred to as the H-H-S (human-human-system) communication analysis framework, which can model the changes in team communication that are emerging in these new working environments. The stage-specific decision-making model and analysis tool of the proposed framework make the analysis of team communication easier by providing visual clues. The usefulness of the proposed framework is demonstrated with an in-depth comparison of the characteristics of communication in the conventional and advanced main control rooms of nuclear power plants.     

机械系统人机界面匹配优度的研究

文章运用多层次模糊综合评判的方法，提出了一种用于评价机械系统人机界面匹配合理程度的评价指标——匹配优度。在该评价指标中包含有机械系统的基本参数，即机械部件的重要性和操作频率、人体生物力学数据和人体参数的统计数据。在运用它对系统进行评价时，除能够得到系统的整体评价外，还能够分别给出手操作类、脚操作类、仪表类和座椅类等组成部分的评价结果。同时，运用匹配优度可以较好地构造系统的评价模型，使之能够完整地体现评价过程中的主、客观因素所起的作用     

‘Little wake turbulence,huh?’ Applying a contemporary model of learning and memory to the American Airlines Flight AA587 accident

Loss of control has become a leading cause of aviation accidents and human error is often recorded as the cause in favour of other factors. This has the effect of downgrading the significance of corrective actions to address deeper systemic issues, and serves the bad-apple theory of human error. This paper uses a model of learning and memory to expand on the analysis of negative training from the AA587 accident, which documented the actions of the First Officer as the probable cause and training as contributory. Evidence from the investigation and our contemporary understanding of learning and memory is used to explain how the experiences of the First Officer fit the scenario in which the accident occurred, such that it is plausible to extend probable cause beyond his actions. The paper develops a model of causal inference that enables analysts to continue probing causality as part of a systems approach.