李鹏程,刘晓慧.核电厂人因失误机理研究:QAP分析[J].,2022,(5):1-15 |
核电厂人因失误机理研究:QAP分析 |
Study on the Mechanism of Human Error in Nuclear Power Plants:QAP Analysis |
投稿时间:2022-09-05 |
DOI: |
中文关键词: 核电厂 人因失误 行为形成因子 人因失误机理 QAP分析 |
English Keywords:nuclear power plants human-caused errors performance shaping factors human error mechanism QAP analysis ( |
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中文摘要: |
为了明确核电厂人因失误机理并为后期人因失误的精准防控提供理论依据,文章采用“组织定向人因失误分析技术”对2010—2020年核电厂208件人因失误事件报告进行分析,获得样本数据,经统计辨识主要的人因失误类型(知识型、规则型和技能型)和影响因素(如教育培训、组织设计、规程、人机界面等),结合影响因素之间的相关性及因子分析构建主要人因失误场景(如知识/技能经验、注意力、压力和态度等)。由于各因素之间存在相互影响,因而采用QAP方法(Quadratic Assignment Procedure,二次指派程序)对人因失误场景进行相关分析和回归分析,建立知识型、规则型、技能型人因失误因果模型,辨识不同的人因失误场景,揭示人因失误机理。结果表明,不同的人因失误类型其产生机理以及场景显著性不同,为人因失误的精准防控提供理论依据。 |
English Summary: |
In order to clarify the mechanism of human errors in nuclear power plants and provide a theoretical basis for the precise prevention and control of human errors in the later stage, the “Organizationally Oriented Human Error Analysis Technique” was used to analyze 208 human error reports in nuclear power plants from 2010 to 2020 and obtain sample data. The main human error scenarios (e.g., knowledge/skill experience, attention, stress, attitude, etc.) were constructed by combining correlation and factor analysis among the influencing factors. Because of the interactions among the factors, QAP analysis (Quadratic Assignment Procedure) was used to correlate and regress the human error scenarios, establish knowledge-based, rule-based, and skill-based human error causal models, identify different human error scenarios, and reveal the human error mechanism. The results show that different human error types have different degrees of importance in their generation mechanisms and influencing factors, which provide theoretical basis for accurate prevention and control of human errors. |
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